3 - Headache Flashcards
5th MC reason to go the ED?
Headache
2.1 million visits/yr
Though 47% or adults suffer from HA only __ are high risk?
With Acute onset aka ___, __ - __ are high risk
4%
Thunderclap HA
10-14%
Primary vs secondary HA?
Primary: ideologic
Secondary: underlying cause i.e. tumor, subarachnoid hemorrhage
Name some red flags:
Onset: sudden, trauma
Sympsoms: altered mental, seizure, fever, visual changes
Meds: Abx, anticoagulants, immunosuppressants
Past hx: change in normal Ha
Associated: preggo, lupus, sarcoidosis
PE red flags with HA
altered mental status fever, neck stiff, papilledema, focal neuro signs
Meningitis triad?
Fever
Altered mental status
Neck stiffness
If you suspect meningitis but cannot get LP (i.e. pt is combative, has coagulopaty etc) you should?
Treat with abx
Worst HA of my life is pathognomonomic for subarachnoid hemorrhage, but how many of theses people actually have it?
10-14%
But it has a 50% survival at 30 days so we care
What is xanthochromia?
A yellow tinge to CSF that indicates a subarachnoid hemorrhage
Steps needed to r/o SAH?
CT If neg LP If neg and hx really suggest Call neuro
Who is getting a CT for a HA regardless of symptoms?
People on antiplatlets and anticoagulants
Acute HA w associated vestibular symptoms?
(Vertigo or ataxia)
Considered cerebellar hemorrhage until proven otherwise
You’re getting a surgical evacuation
What about a brain tumor causes a HA?
CSF obstruction
intracranial Hypertension
Signs suggesting brain tumor?
HA with:
Abnormal neuro Worsened by valsalva Awakening from sleep Seizures Cancer diagnosis Mental status change
Study or choice for brain tumor?
MRI with and w/o gandolinium
CT will see large masses but isnt as good
Pts with new onset HA you need to worry about?
Cerebral venous thrombosis
Presentation can vary greatly
Known risk factors for cerebral venous thrombosis?
Women
Peripartum
Recent surg hx
Hypercoagulable states
Cerebral venous thrombosis presentation?
Varies greatly from benign to seizure, stroke and coma
If abnormal CT or MRI with focal neurologic deficit or altered mental you need to order? (Definitive diagnosis)
Magnetic resonance venography
Cerebral venous thrombosis LP?
Yes you can safely do it
Elevated opening pressure prompts more tests
What is posterior reversible encephalopathy syndrome?
Encephalopathy symptoms
Marked BP elevation
MRI: symmetrical vasogenic edema in occipital area
TX for posterior reversible encephalopathy syndrome?
BP management
Supportive care
What can mimic subarachnoid hemorrhage?
Reversible cerebral vasoconstriction syndrome
Warning signs for reversible cerebral vasoconstriction?
- Multiple “thunderclap” HA w/in a few weeks
- Subarachnoid hemorrhage is neg
- Women in early 40’s
Though some pts with reversible cerebral vasoconstriction syndrome present with seizures and focal neuro ___ is often the only presenting symptom.
severe headache
What is the key diagnostic feature of reversible cerebral vasoconstriction syndrome?
Multiple areas of cerebral vasoconstriction on cerebral angiography
Usually found between 2 and 3 weeks after onset
Imaging can take weeks and is sometimes not clear so diagnosis of reversible cerebral vasoconstriciton syndrome is often made by?
Presentation of thunderclap HA
W/o subarachnoid hemorrhage
This should at least prompt a consult with neuro
Pt presents with:
- Fatigue
- fever
- proximal muscle weakness
- jaw claudication
- TIA symptoms (transient vision loss)
Temporal arteritis
Aka “giant cell arteritis”
Temporal arteritis must have what labs?
ESR must be high
Check IOP to exclude glaucoma
Tx for temporal arteritis?
Prednisone 60mg q day
Giant cell arteritis must have 3 out of 5 of the following for diagnosis:
- > 50 yrs
- new HA
- temporal artery abnormality (TTP etc)
- ESR >/=50
- abnormal artery biopsy
Migraine is defined as:
HA with:
- moderate - severe
- lasts 4 -72 hrs
- unilateral/pulsatile (usually)
- photophobia and phonophobia
- made worse by activity
Definition of chronic migraine?
5+ migraine HA days per month over 3 months
1st line abortive therapy for migraines?
Triptans are first line abortive therapy
If abortive therapy fails pts get rescue therapy which is:
IV hydration
NSAIDS
Antiemitic
Diphenhydramine (20-50mg IV)
Diphenhydramine helps with migrains b/c histamine levels correlate with migraine attacks but what else does it do?
Helps treat akathisias from antiemetics
What are akathisias?
A feeling of muscle quivering, restlessness, and inability to sit still, sometimes a side effect of antipsychotic or antidepressant medication.
Tx options for migrains
Chart on 29 and 30
I’ll make cards if he makes a big deal about it
Pregnancy considerations for migraines?
No good data but:
Tylenol, opoids, steroids: yes
Metoclopramide : yes
NSAIDS: until 3rd trimester
Triptans: NO
Ergotamines: FUCK NO
ED fixes migraines right?
Not usually. Over 1/2 will have some residual HA
You send them home with abortive meds
Who gets idiopathic intracranial hypertension?
Obese women between 20 and 44 yrs and has trended up with obesity epidemic
Idiopathic intracranial hypertension is aka?
Pseudotumor cerebri
Symptoms of pseudotumor cerebri?
HA
Transient visual obscurations (32%)
Back pain
Puslsatile tinnitis
If you dont treat idiopathic intracranial hypertension what do you win?
Can lead to permanent visual impairment
Diagnostic criteria for idiopathic intracranial hypertension?
- Papilledema (otherwise normal neuro)
- H opening pressure on LP
— >25 in adults and >28 in kids - normal CSF composition
- normal imaging
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?
- Empty sella
- Flattening of posterior aspect of globe
- Distension of perioptic subarachnoid space
- Tortuous optic nerve
- Transverse venous sinus stenosis
What is both diagnostic and therapeutic for pseudotumor cerebri?
LP: needed for diagnosis
- lowered pressure provides temporary relief
How much does each ml of CSF lower CSF fluid pressure (in general)
What if i remove too much?
1mL of CSF with lower Pressure by 1cm H20
Low pressure HA
Meds for idiopathic intracranial hypertension?
acetazolamide PO 250-500mg BID
Up to 4gm/day but adjust dose under supervision of neuro
Long term tx for pseudotumor cerebri may include?
Shunting of CSF
Optic nerve sheath fenestration
Wt loss (LOL)
Cluster HA may mimic?
Dental pain
Distinguishing feature for cluster HA?
The need to pace
Tx for cluster HA?
100% O2: 12L/min x 15 min - NRB
Sumatriptan 6mg SC
Cluster HA must have at least 5 attacks with the following criteria:
Severe
Unilateral
15-180 min
Circadian/circannual
Associated ipisilateral symptoms for cluster HA?
Pt must have at least 1
Lacrimation Conjunctival injection Nasal conjunction Ptosis and/or miosis Edema or eyelid/face Sweating of forehead/face
How is coital HA diagnosed?
Diagnosis of exclusion
Must have imaging
What is a valsalva associated HA?
Thunderclap HA triggered by valsalva, cough, straining with normal neuroimaging
Severe HA in older pts?
Bad sign, cluster, tension and migraine HA incidence decrease with age so this is not promising
What is a intracerebral aneurysmal leak?
Aka sentinal hemorrhage or herald bleed
Can precede catastrophic aneurysmal rupture
Fever with HA raises concerns for?
CNS infection
- meningitis
- encephalitis
- brain abscess
Family hx of autosomal dominant polycystic kidney disease has an increased risk for?
Intracranial aneurysm
Why must acute angle-closure glaucoma be considered with severe HA?
The pain can be so sever that the pt may fail to localize pain to the eye
___ can be seen in the presence of raised ICP
Papilledema
Can persist after ICP drops
Lab tests for HA?
Routine blood tests dont help much but we still look at:
- BMP
- CBC
- Coagulation panel (coags)
- ESR
- blood culture
- CSF analysis
You come to the ED with a HA what imaging are you getting?
Depends on HX PE bla bla bla
Youre probably getting a non contrast CT
When is MRI useful in HA?
Detecting arterial disease - stenosis
- congenital anomalies
- dissection
- CNS vasculitis
Radiology can recommend which type of MRI is best
LP is warranted for which HA’s?
Diagnostic:
- Meningitis
- SA hemorrhage
- intracranial HOTN
- Carcinomatous meningitis
Therapeutic:
- Pseudotumor cerebri
Factors that indicate LP is probably safe?
No hx of immunosuppression
Normal sensorium
No focal neruo deficits
Suspected bacterial meningitis
Factors indicate may not be safe for meningitis?
Clinical signs of impending herniation
Clinical features that show CT will prob be abnormal?
Deteriorating LOC Brainstem signs Focal neuro Recent seizures Preexisting neuro Immunocompromised state
Common pathogens that infect CSF?
S. Pneumo (head trauma) GBS N. Meningitis (close quarters) H. Influenza (antivaxers) L. Monocytogenes (ETOH)
S. Aureus/strep (post-craniotomy)
Never perform LP if:
Coagulopathy
Platelet < 20000/uL or INR >1.5
CSF eval chart
Slide 65 “treat yo self”
He said to make sure you know it
If you suspect meningitis:
Never delay abx for LP (i know you know this but it is bolded red, underlined and mentioned several times)
What Empiric abx does the ed use?
18-49: ceftriaxone 2gm IV + vanc 15mg/kg IV
50+: add ampicillin 2mg IV
Cepepime + vanc if recent neurosurgery
Bacterial meningitis with sever pcn allergy?
Replace ceptriaxone with chloramphenicol and
ampicillin with trimethoprim-sulfamethoxazole
What should be given before the 1st does of abx to reduce inflammation?
Dexamethasone
Unless they are already on abx
Bacterial meningitis found in close living quarters?
N. Meningitis
Bacterial meningitis found in antivaxers kids?
H. Influenza
Its their kids b/c their parents made them get the vaccine so they’re g2g
Bacterial meningitis found in alcoholics and the elderly?
L. Monocytogenes
Bacterial meningitis found in penetrating Head trauma?
S. Pneumoniae
Bacterial meningitis found post-craniotomy?
S. Aureus
Streptococci
Private Joker: A day without blood:
Is like a day without sunshine
