3 Headache, pt 2 Flashcards
The most common non-life-threatening headache in the ED
Migraine
Features of Migraine
Pulsatile, throbbing
Photosensitivity, phonosensitivity
Lasts hOurs (4-72 hours)
Unilateral
Nausea, vomiting
Debilitating, worse with exertion
4/5 has positive likelihood ratio of 24 for migraine
Chronic migraine is defined as
5 or more migraine headache days per month over the past 3 months
First-line abortive therapy for migraine at home
Triptans
ED treatment of migraine
Dopamine receptor antagonist (metoclopramide, droperidol)
+ NSAIDs
Steroids may be useful to reduce the risk for headache recurrence after ED discharge
Opiates in migraine
Opiates and barbiturate-containing compounds should not be used routinely for abortive migraine thearpy unless other standard treatments fail
Remarks on cluster headache
severe (excruciating)
unilateral
lasts 15-180 mins (brief and self-limited)
Circardian / circannual
Can mimic dental pain
More common in men
distinguishing feature of cluster headache
the need for the patient to “pace”
Treatment of cluster headache
100% oxygen administered at 12L/min for 15 mins through NRM
Sumatriptan, 6 mg SC
Presentation of PRES
Posterior Reversible Encephalopathy Syndrome
severe headache,
visual changes,
seizures,
encephalopathy
marked hypertension
PRES is most common in
Patients undergoing active treatment with immune-suppresing or -modulating medications
or chemotheraptuic agents,
and in end-stage renal disease
Imaging findings in PRES
MRI: symmetrical vasogenic edema in the occipital area of the brain
Treatment of PRES
BP control and supportive care
This condition can mimic subarachnoid hemorrhage
RCVS
Reversible cerebral vasoconstriction syndrome
characterized by the occurrence of 1 or more “thunderclap” headache
should be considered only when the evaluation for SAH has proven negative
also mimic SAH: CVT, carotid artery dissection
Diagnosis of RCVS
- The clinical presentation of thunderclap headache without evidence of SAH should be the main prompt to making this diagnosis or consulting with a neurologist
- Head CT is most commonly normal
- the key diagnostic feature (multiople areas of cerebral vasoconstriction on MRA) is most commonly found on follow-up angiography between 2 and 3 weeks after symptom onset
Remarks on occipital neuralgia
paroxysms of pain at the back of the head
described as stabbing or electric shock-like
Treatment in occipital neuralgia
occipital nerve block typically results in marked improvement of symptoms
- results can persist for weeks after injection
- both diagnostic and therapeutic
- can be performed with easy in any setting and requires minimal expertise
remarks on idiopathic intracranial hypertension
- aka pseudotumor cerebri
- most common in obese women
- if untreated, can lead to permanent vsual impairment
diagnostic criteria of idiopathic intracranial hypertension
papilledema
otherwise normal neurologic exam
elevated opening pressure on LP (>25 cm H2O in adults, >28 cm H2O in children)
normal CSF composition
normal imaging
treatment of idiopathic intracranial hypertension
Focused on preservation of vision
LP may provide temporary relief of symptoms (target pressure of 15-20 cm H2O)
In general, removal of 1 mL of CSF will lower the CSF pressure by about 1 cm H2O
Detecting increased ICP
US of the optic nerve sheath diameteter
<5 mm is normal
>6 mm is abnormal
5-6 mm is controversion
Clinical feature of intracranial hypotension
AKA low-pressure headache
Headache that increases in severity with upright posture but improves or resolves in the supine position
LP, if performed, should have an opening pressure <6 cm H2O
Most effective therapy for low-pressure headache
epidural blood patch, typically performed by anesthesiologists
Hypertensive headache
There is no compelling evidence linking mild to moderate hypertension with headache.
Pituitary tumor apoplexy requires immediate treatment with
corticosteroids
and urgen neurosurgical consultation
Most common tumor of the third ventricle
Third ventricle collloid cysts
- rare cause of acute neurologic deterioration and sudden death
- usually congenital
- hx of severe paroxysmal and episodic attacks of (typicall frontal) headache with N/V
- the presumptive cause is the intermittent obstruction of CSF flow through the foramina of Monro
Acute angle-closure glaucoma diagnosis includes ocular pressure greater than
21 mm Hg
although this is usually greater than 30 mm Hg
Remarks on preeclampsia
May present with headache
after 20 weeks AOG up to 6 weeks postpartum
Proteinuria is NOT required for diagnosis
Remarks on CVT
Cerebral Venous Thrombosis
Mean age of 39 years
More common in women
May present with a “thunderclap” headache
Diagnosed definitively with magnetic resonance venography
LP can safely be performed in patients with CVT
