HeadacheUniversity of Utah Emergency Medicine

Medical Student Rotation

Objectives

•Describe high risk features of headaches

•Describe appropriate work-up for high risk headache

•List common causes of headaches

•Describe treatment for common headache syndromes.

Case 1•39 y/o male presents with severe

headache

•Began 4 hrs prior to presentation

•Associated with nausea and photophobia

•Vitals T 38.1 RR 20 BP 150/92 HR 110

•Exam / Additional history ?

•Differential ?

High Risk features• Onset - sudden / maximal at onset (<1 min lasting > 1 hr) - 15-25% association with SAH, up to 37% associated with some

serious pathology.

• Exertional - 10% associated with organic pathology

• Fever - associated with infections, autoimmune, SAH

• Meningsmus - only 50% of pts with meningitis demonstrate on exam.

• Age - over 55 with new headache 10-15% associated with organic pathology

• Abnl neuro findings or mental status

• HIV, SLE, Cancer, Immunocompromise

• Persistent Headache > 2 months

• ————

Evaluation

•What tests do you want to order?

•Why?

Neuroimaging

•CT - non contrasted

•sensitivity for SAH is time dependent and probably equipment and reader dependent

•up to 97% sensitive in first 12 hrs

•90 % first 24 hrs, 50% by 1 week.

Neuroimaging

• Contrasted CT - indications HIV, immunosuppression - useful for intracerebral fungal infections

• CTA, MRI/MRA - 85-95% sensitive for cerebral aneurysm - CTA better, higher miss rate with <5mm or with vasospasm

• Currently no radiologic study adequate to exclude SAH - estimates from 0-15% missed with CT only workup in first 24 hrs.

Lumbar Puncture•CSF shows RBC and xanthrochromia with

SAH. Rapidly diffuse into CSF, though may have false negatives before 2 hrs after bleed

•20% of taps are traumatic

•Constant RBC from tube 1 - 4 very concerning

• Infections - increased WBC, low glucose, high protein

CT Scan shows SAH

•Blood between pia and arachnoid

•80% from aneurysms. High mortality (50% in 6 months) and permanent deficits (33%)

•30-50% have sentinal bleed around 2 weeks prior to rupture.

•Linear increase with age from 24. Average age around 50.

Case 2

•43 y/o female with headache, N/V, photophobia

•Preceding wavy visual loss

•VS T 37.2 RR 12 HR 100 BP 150/87

•Exam / Additional History?

•Workup / Treatment ?

Migraine• 90% of ED headaches - Migraine, Tension, Mixed

benign

• Spectrum - Migraine with aura (classic), Migraine without aura (common), tension

• Dopamine, Serotonin, inflammatory peptides ---> Vasodilatation, peri-vascular inflammation

• Women > men, usually start prior to age 30. Age over 55 at onset more predictive of organic pathology

• 80% have FH of migraine.

• 20% with aura, 80% without aura, 40% bilateral

Migraine Treatment

• Dopamine antagonists

• Compazine > Reglan IV 85% effective in acute attacks, less effective for >24hrs

• Also Haldol, Thorazine

• NSAID’s - block prostaglandin and serotonin release, inhibit platelet aggregation, first line out pt therapy

• Ergotamines (DHE) - inhibit serotonin, cerebral vasoconstrictor - caution or don’t give with angina, poorly controlled hypertension, peripheral vascular disease, MAOI’s

• 5HT1 agonists - cause vasoconstriction and suppress inflammation Maxalt, Imitrex, Zomig - caution or contraindicated with CAD/angina, HTN, PVD, MAOI’s.

• Narcotics - not first line therapy, rescue only, may cause rebound headaches, contribute to chronic daily headaces and analgesic overuse headaches, should generally be avoided.

Case 3•72 y/o female with 5 days of temporal

parietal area headache, relative acute onset.

•Complains of intermittent double vision

•VS T38.1 RR 12 BP 128/82 HR 84

•Exam/Additional History?

•Work-up?

Temporal Arteritis• Chronic systemic vasculitis medium and large arteries

• Over 50 years old mean 72, F>M

• Visual loss worst complication - up to 33% with bilat visual loss

• Generally sudden onset temporal headache, can be anywhere, visual loss can be painless. Systemic symptoms common, fever, weight loss, anorexia, mailaise, memory impairment.

• Polymyalgia Rheumatica - sig overlap, sudden shoulder girdle pain

• Dx. -age over 50, headache, ESR > 50, temp art tender or positive biopsy. Also consider CRP.

• Treatment consists of steroid treatment if suspected and temporal artery biopsy within one week.

Case 4•21 y/o obese female with diffuse

aching headache for 1-2 weeks

•“Whoosing in my ears”

•Occasional dimming of vision, esp after standing up lasts for a few seconds

•Recent PMH - Macrobid for UTI

•Exam/Workup?

Idiopathic Intracranial

Hypertension• 8:1 Female to male, incidence increases with weight over normal

•Nonspecific variable headache.

• Pulsatile tinnitus

• Visual - transient visual loss or dimming, bilat or unilat. May have horizontal diplopia (6th CN impairment), may have sudden visual loss from intraocular hemorrhage after chronic papilledema

Work-up•CT - r/o other causes

•MRI with gadolinium, MRV - excludes dural venous thrombosis, malignancy, inflammatory conditions

•SLE w/u esp in males and non-obese pts

•Medication history - lots of meds, including Bactrim, macrobid, lithium, Accutane, tagamet, steroids, norplant, tamoxifen, tetracycline, etc

Work-up•Physical exam

•Papilledema

•Visual field deficit - esp inferior nasal quadrent

•Increased optic nerve diameter

•Unilateral or bilateral 6th nerve palsy (psuedo-localizing)

Lumbar puncture•Opening pressure - greater than 25 cm

in obese pts, or 20 cm in non-obese

•Best performed lateral decubitus

•may require sitting position in obese pts

•transition to side after successful puncture

•20 cc large volume tap is therapeutic

Treatment• Important to preserve visual function

•Diamox (CA inhibitor) 250 mg po qid

• Steroids - for emergent treatment of visual loss

• VP or LP shunt. Optic nerve fenestrations (more effective in some studies)

•Weight loss

•Discontinue offending agents

Case 5•33 y/o Male with severe left temporal

and peri-orbital pain, sharp, severe, intermittent, lasts 10-15 minutes at a time

•Symptoms have been going on for 1 week, worsening

•Pt screaming and holding head intermittently during evaluation

•Further History/exam/WU?

Cluster headaches•Predominantly male (2:1) mean onset 30

years old

•Episodic or chronic

•Attacks are unilat, last minutes to hours, peak over 10-15 minutes (remember SAH maximal within 1 minute) associated with unilat rhinorrhea, lacrimation, conjunctival injection, Horner’s syndrome (ptosis, miosis, anhydrosis)

Causes•Unknown

•Trigeminal nerve involved (V1,V2)

•Vasodilation

•Histamine

•Circadian

•80% smokers, 50% heavy ETOH use (may trigger attacks during symptomatic interval)

Treatment•Oxygen - during initial phase of attack,

questionable value

• Imitrex and DHE - treatment of choice

•Corticosteroids - 8-12 hrs maximal 2-3 days

•Capaiscan to nostril, Lidocaine 1 cc of 10% with swab to each nostril (MAD atomizer?)

•Narcotics, NSAIDS, abuse potential

Case 6•65 y/o male

•Sharp pain shoots down face to nose and jaw. Triggered by shaving, touch to face. “Feels like I’m being electrocuted Doc” lasts few seconds at time.

•Pt has twitching and spasm of side of face several times during history.

•Normal PE except...

•

Trigeminal Neuralgia

• Unclear etiology - caused by pain from trigeminal nerve, usually V2 and V3 (V1 and V2 in cluster headaches)

• Older pts - 60 + (in younger patient consider secondary causes, MS, nerve comp etc - MRI)

• Aborting attacks - treatment of choice Tegretol with or without Baclofen

• Severe constant attacks may be aborted with IV dilantin

• Neurontin, Topamax, Lamictal, Depakote, Clonazepam

Thats All !