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Senior - E Med > 3 - Headache > Flashcards

3 - Headache Flashcards

1
Q

5th MC reason to go the ED?

A

Headache

2.1 million visits/yr

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2
Q

Though 47% or adults suffer from HA only __ are high risk?

With Acute onset aka ___, __ - __ are high risk

A

4%

Thunderclap HA
10-14%

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3
Q

Primary vs secondary HA?

A

Primary: ideologic

Secondary: underlying cause i.e. tumor, subarachnoid hemorrhage

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4
Q

Name some red flags:

A

Onset: sudden, trauma

Sympsoms: altered mental, seizure, fever, visual changes

Meds: Abx, anticoagulants, immunosuppressants

Past hx: change in normal Ha

Associated: preggo, lupus, sarcoidosis

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5
Q

PE red flags with HA

A 
altered mental status 
fever, 
neck stiff, 
papilledema,
focal neuro signs
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6
Q

Meningitis triad?

A

Fever
Altered mental status
Neck stiffness

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7
Q

If you suspect meningitis but cannot get LP (i.e. pt is combative, has coagulopaty etc) you should?

A

Treat with abx

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8
Q

Worst HA of my life is pathognomonomic for subarachnoid hemorrhage, but how many of theses people actually have it?

A

10-14%

But it has a 50% survival at 30 days so we care

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9
Q

What is xanthochromia?

A

A yellow tinge to CSF that indicates a subarachnoid hemorrhage

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10
Q

Steps needed to r/o SAH?

A 
CT 
If neg
LP 
If neg and hx really suggest
Call neuro
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11
Q

Who is getting a CT for a HA regardless of symptoms?

A

People on antiplatlets and anticoagulants

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12
Q

Acute HA w associated vestibular symptoms?

A

(Vertigo or ataxia)

Considered cerebellar hemorrhage until proven otherwise

You’re getting a surgical evacuation

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13
Q

What about a brain tumor causes a HA?

A

CSF obstruction

intracranial Hypertension

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14
Q

Signs suggesting brain tumor?

A

HA with:

Abnormal neuro
Worsened by valsalva
Awakening from sleep
Seizures
Cancer diagnosis
Mental status change
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15
Q

Study or choice for brain tumor?

A

MRI with and w/o gandolinium

CT will see large masses but isnt as good

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16
Q

Pts with new onset HA you need to worry about?

A

Cerebral venous thrombosis

Presentation can vary greatly

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17
Q

Known risk factors for cerebral venous thrombosis?

A

Women
Peripartum
Recent surg hx
Hypercoagulable states

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18
Q

Cerebral venous thrombosis presentation?

A

Varies greatly from benign to seizure, stroke and coma

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19
Q

If abnormal CT or MRI with focal neurologic deficit or altered mental you need to order? (Definitive diagnosis)

A

Magnetic resonance venography

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20
Q

Cerebral venous thrombosis LP?

A

Yes you can safely do it

Elevated opening pressure prompts more tests

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21
Q

What is posterior reversible encephalopathy syndrome?

A

Encephalopathy symptoms
Marked BP elevation
MRI: symmetrical vasogenic edema in occipital area

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22
Q

TX for posterior reversible encephalopathy syndrome?

A

BP management

Supportive care

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23
Q

What can mimic subarachnoid hemorrhage?

A

Reversible cerebral vasoconstriction syndrome

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24
Q

Warning signs for reversible cerebral vasoconstriction?

A
  • Multiple “thunderclap” HA w/in a few weeks
  • Subarachnoid hemorrhage is neg
  • Women in early 40’s
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25
Q

Though some pts with reversible cerebral vasoconstriction syndrome present with seizures and focal neuro ___ is often the only presenting symptom.

A

severe headache

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26
Q

What is the key diagnostic feature of reversible cerebral vasoconstriction syndrome?

A

Multiple areas of cerebral vasoconstriction on cerebral angiography

Usually found between 2 and 3 weeks after onset

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27
Q

Imaging can take weeks and is sometimes not clear so diagnosis of reversible cerebral vasoconstriciton syndrome is often made by?

A

Presentation of thunderclap HA
W/o subarachnoid hemorrhage

This should at least prompt a consult with neuro

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28
Q

Pt presents with:

  • Fatigue
  • fever
  • proximal muscle weakness
  • jaw claudication
  • TIA symptoms (transient vision loss)
A

Temporal arteritis

Aka “giant cell arteritis”

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29
Q

Temporal arteritis must have what labs?

A

ESR must be high

Check IOP to exclude glaucoma

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30
Q

Tx for temporal arteritis?

A

Prednisone 60mg q day

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31
Q

Giant cell arteritis must have 3 out of 5 of the following for diagnosis:

A
  • > 50 yrs
  • new HA
  • temporal artery abnormality (TTP etc)
  • ESR >/=50
  • abnormal artery biopsy
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32
Q

Migraine is defined as:

A

HA with:

  • moderate - severe
  • lasts 4 -72 hrs
  • unilateral/pulsatile (usually)
  • photophobia and phonophobia
  • made worse by activity
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33
Q

Definition of chronic migraine?

A

5+ migraine HA days per month over 3 months

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34
Q

1st line abortive therapy for migraines?

A

Triptans are first line abortive therapy

35
Q

If abortive therapy fails pts get rescue therapy which is:

A

IV hydration
NSAIDS
Antiemitic
Diphenhydramine (20-50mg IV)

36
Q

Diphenhydramine helps with migrains b/c histamine levels correlate with migraine attacks but what else does it do?

A

Helps treat akathisias from antiemetics

37
Q

What are akathisias?

A

A feeling of muscle quivering, restlessness, and inability to sit still, sometimes a side effect of antipsychotic or antidepressant medication.

38
Q

Tx options for migrains

A

Chart on 29 and 30

I’ll make cards if he makes a big deal about it

39
Q

Pregnancy considerations for migraines?

A

No good data but:

Tylenol, opoids, steroids: yes
Metoclopramide : yes
NSAIDS: until 3rd trimester

Triptans: NO
Ergotamines: FUCK NO

40
Q

ED fixes migraines right?

A

Not usually. Over 1/2 will have some residual HA

You send them home with abortive meds

41
Q

Who gets idiopathic intracranial hypertension?

A

Obese women between 20 and 44 yrs and has trended up with obesity epidemic

42
Q

Idiopathic intracranial hypertension is aka?

A

Pseudotumor cerebri

43
Q

Symptoms of pseudotumor cerebri?

A

HA
Transient visual obscurations (32%)
Back pain
Puslsatile tinnitis

44
Q

If you dont treat idiopathic intracranial hypertension what do you win?

A

Can lead to permanent visual impairment

45
Q

Diagnostic criteria for idiopathic intracranial hypertension?

A
  • Papilledema (otherwise normal neuro)
  • H opening pressure on LP
    — >25 in adults and >28 in kids
  • normal CSF composition
  • normal imaging
46
Q

In the absence of either papilledema or abducens nerve palsy diagnosis of pseudotumor without papilledema can be made if at least 3 of the following?

A
  1. Empty sella
  2. Flattening of posterior aspect of globe
  3. Distension of perioptic subarachnoid space
  4. Tortuous optic nerve
  5. Transverse venous sinus stenosis
47
Q

What is both diagnostic and therapeutic for pseudotumor cerebri?

A

LP: needed for diagnosis

- lowered pressure provides temporary relief

48
Q

How much does each ml of CSF lower CSF fluid pressure (in general)

What if i remove too much?

A

1mL of CSF with lower Pressure by 1cm H20

Low pressure HA

49
Q

Meds for idiopathic intracranial hypertension?

A

acetazolamide PO 250-500mg BID

Up to 4gm/day but adjust dose under supervision of neuro

50
Q

Long term tx for pseudotumor cerebri may include?

A

Shunting of CSF

Optic nerve sheath fenestration

Wt loss (LOL)

51
Q

Cluster HA may mimic?

A

Dental pain

52
Q

Distinguishing feature for cluster HA?

A

The need to pace

53
Q

Tx for cluster HA?

A

100% O2: 12L/min x 15 min - NRB

Sumatriptan 6mg SC

54
Q

Cluster HA must have at least 5 attacks with the following criteria:

A

Severe
Unilateral
15-180 min
Circadian/circannual

55
Q

Associated ipisilateral symptoms for cluster HA?

A

Pt must have at least 1

Lacrimation
Conjunctival injection
Nasal conjunction
Ptosis and/or miosis
Edema or eyelid/face
Sweating of forehead/face
56
Q

How is coital HA diagnosed?

A

Diagnosis of exclusion

Must have imaging

57
Q

What is a valsalva associated HA?

A

Thunderclap HA triggered by valsalva, cough, straining with normal neuroimaging

58
Q

Severe HA in older pts?

A

Bad sign, cluster, tension and migraine HA incidence decrease with age so this is not promising

59
Q

What is a intracerebral aneurysmal leak?

A

Aka sentinal hemorrhage or herald bleed

Can precede catastrophic aneurysmal rupture

60
Q

Fever with HA raises concerns for?

A

CNS infection

  • meningitis
  • encephalitis
  • brain abscess
61
Q

Family hx of autosomal dominant polycystic kidney disease has an increased risk for?

A

Intracranial aneurysm

62
Q

Why must acute angle-closure glaucoma be considered with severe HA?

A

The pain can be so sever that the pt may fail to localize pain to the eye

63
Q

___ can be seen in the presence of raised ICP

A

Papilledema

Can persist after ICP drops

64
Q

Lab tests for HA?

A

Routine blood tests dont help much but we still look at:

  • BMP
  • CBC
  • Coagulation panel (coags)
  • ESR
  • blood culture
  • CSF analysis
65
Q

You come to the ED with a HA what imaging are you getting?

A

Depends on HX PE bla bla bla

Youre probably getting a non contrast CT

66
Q

When is MRI useful in HA?

A

Detecting arterial disease - stenosis

  • congenital anomalies
  • dissection
  • CNS vasculitis

Radiology can recommend which type of MRI is best

67
Q

LP is warranted for which HA’s?

A

Diagnostic:

  • Meningitis
  • SA hemorrhage
  • intracranial HOTN
  • Carcinomatous meningitis

Therapeutic:
- Pseudotumor cerebri

68
Q

Factors that indicate LP is probably safe?

A

No hx of immunosuppression
Normal sensorium
No focal neruo deficits

Suspected bacterial meningitis

69
Q

Factors indicate may not be safe for meningitis?

A

Clinical signs of impending herniation

70
Q

Clinical features that show CT will prob be abnormal?

A 
Deteriorating LOC
Brainstem signs
Focal neuro
Recent seizures
Preexisting neuro 
Immunocompromised state
71
Q

Common pathogens that infect CSF?

A 
S. Pneumo (head trauma)
GBS
N. Meningitis (close quarters)
H. Influenza (antivaxers)
L. Monocytogenes (ETOH)

S. Aureus/strep (post-craniotomy)

72
Q

Never perform LP if:

A

Coagulopathy

Platelet < 20000/uL or INR >1.5

73
Q

CSF eval chart

A

Slide 65 “treat yo self”

He said to make sure you know it

74
Q

If you suspect meningitis:

A

Never delay abx for LP (i know you know this but it is bolded red, underlined and mentioned several times)

75
Q

What Empiric abx does the ed use?

A

18-49: ceftriaxone 2gm IV + vanc 15mg/kg IV

50+: add ampicillin 2mg IV

Cepepime + vanc if recent neurosurgery

76
Q

Bacterial meningitis with sever pcn allergy?

A

Replace ceptriaxone with chloramphenicol and

ampicillin with trimethoprim-sulfamethoxazole

77
Q

What should be given before the 1st does of abx to reduce inflammation?

A

Dexamethasone

Unless they are already on abx

78
Q

Bacterial meningitis found in close living quarters?

A

N. Meningitis

79
Q

Bacterial meningitis found in antivaxers kids?

A

H. Influenza

Its their kids b/c their parents made them get the vaccine so they’re g2g

80
Q

Bacterial meningitis found in alcoholics and the elderly?

A

L. Monocytogenes

81
Q

Bacterial meningitis found in penetrating Head trauma?

A

S. Pneumoniae

82
Q

Bacterial meningitis found post-craniotomy?

A

S. Aureus

Streptococci

83
Q

Private Joker: A day without blood:

A

Is like a day without sunshine

Senior - E Med (8 decks)

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