Acute Headache

Question 1

Evidence based symptom evaluation

Answer 1

-symptoms clinical epidemiology & disease candidates
-Bayesian principles: likelihood of a specific disease depending on patient demographic, comorbidities, and clinical features

Question 2

general inquiries for acute headache

Answer 2

• > 40 years age
  -rapid onset and severe intensity, trauma, onset during exertion
  -fever, vision changes, neck stiffness
  -HIV infection
  -current or past hx of hypertension
  -neurologic findings (mental status change, motor or sensory deficit, loss of consciousness)

Question 3

Acute headache

Answer 3

-5th most common reason for ED visit
-2nd most common reason for neurologic consultation in ED
-nontraumatic
-challenge: identifying if pt presenting with an uncommon but life threatening condition (appox 1%)

Question 4

sentinel headache

Answer 4

-before a subarachnoid hemorrhage
-sudden, intense, persistent
-can be days/weeks before hemorrhage

Question 5

Migraine therapies

Answer 5

-serotonin receptor antagonists or ketorolac
-diminution of headache in response to therapies does not rule out critical conditions such as subarachnoid hemorrhage or meningitis

Question 6

COVID-19

Answer 6

-can cause acute headache
-increase migraine frequency
-worsening of chronic migraines
-may increase frequency of cerebral venous thrombosis and cerebral venous sinus thrombosis

Question 7

Causes of acute headache that require immediate treatment

Answer 7

-imminent or completed vascular events (intracranial hemorrhage, thrombosis, cavernous sinus thrombosis, vasculitis, malignant hypertension, arterial dissection, cerebral venous thrombosis, transient ischemic attack, or aneurysm)
-infections (abscess, encephalitis, or meningitis), intracranial masses causing intracranial hypertension, preeclampsia
-carbon monoxide poisoning and methemoglobinemia

Question 8

thunderclap headache

Answer 8

-sudden onset headache that reaches maximal and severe intensity within seconds or a few minutes
-work up for subarachnoid hemorrhage (estimated prevalence 43%)
-during postpartum precipitated by the valsalva maneuver or recumbent positioning may indicate reversible cerebral vasoconstriction syndrome or irreversible cerebral venous sinus thrombosis -> venous specific imaging for dx

Question 9

Reasons a headache may need workup

Answer 9

-headaches brought on by cough, exertion, or sexual activity
-headache in pt older than 50 or HIV infection -> immediate neuroimaging
-hypertension / malignant hypertension
-pregnant pts -> preeclampsia
-hx of hypercoagulability -> increased risk of cerebral venous thrombosis

Question 10

pheochromocytoma

Answer 10

-episodic headache associated with the triad: hypertension, palpitations, and sweats
-suggestive of pheochromocytoma

Question 11

Dx of headache

Answer 11

-3 or more of the following symptoms: nausea, photophobia, phonophobia, and exacerbation by physical activity
-only one or two of these symptoms rules out migraine (provided one is not nausea)
-SNNOOP10- screening method for secondary causes of headache

Question 12

acute headache physical examination

Answer 12

-vital signs, neurologic exam, vision testing with funduscopic exam
-if fever positive -> meningeal inflammation tests -> kerning and brudzinski signs (absence of jolt accentuation cannot rule out meningitis)
-pts over 60 should be examined for scalp or temporal artery tenderness
-visual acuity, ocular gaze, visual fields, pupillary defects, optic disks, and retinal vein pulsations
-mental status, motor, and sensory systems, reflexes, gait, cerebellar function, and pronator drift -> any abnormalities warrant emergent neuroimaging

Question 13

Diminished visual acuity

Answer 13

suggestive of glaucoma, temporal arteritis, or optic neuritis

Question 14

ophthalmoplegia or visual field defects

Answer 14

-may be signs of venous sinus thrombosis, tumor, or aneurysm

Question 15

afferent pupillary defects

Answer 15

-can be due to intracranial masses or optic neuritis

Question 16

acute severe hypertensive retinopathy

Answer 16

-headache
-hypertension
-retinal cotton wool spots
-flame hemorrhages
-disk swelling

Question 17

horner syndrome

Answer 17

-ipsilateral ptosis and miosis
-ipsilateral ptosis, miosis, and acute headache may signify carotid artery dissection

Question 18

elevated intracranial pressure

Answer 18

-papilledema or absent retinal venous pulsations
-neuroimaging is to be done prior to lumbar puncture

Question 19

Noncontrast head CT

Answer 19

-excludes intracranial hypertension with impending herniation, intracranial hemorrhage, and many types of intracranial masses

Question 20

contrast head CT

Answer 20

-ordered only after a normal noncontrast head CT

Question 21

Lumbar puncture

Answer 21

-normal neuroimaging does not rule out subarachnoid hemorrhage -> lumbar puncture
-if a CT scan was performed less than 6 hours after headache onset and shows no subarachnoid hemorrhage -> lumbar puncture may be withheld
-excludes infectious causes of headaches (especially pts with fever or meningeal signs)
-CSF test should include gram stain, WBC w/ diff, RBC, glucose, total protein, and bacterial culture -> syphilis, cryptococcal antigen (HIV positive pts), acid fast vacillus stain and culture, and complement fixation and culture for coccidioidmycosis when appropriate
-extra 5ml tube is to be taken for potential future testing
-PCR for specific infectious pathogens for pts with evidence of CNS infection but no identifiable pathogen
-can cause headache -> lay down after, from possible leakage of CSF through puncture site

Question 22

Angiography

Answer 22

-pts with high level of suspicion for subarachnoid hemorrhage or aneurysm, a normal CT and lumbar puncture should get a angiography within the next few days

Question 23

Ottawa subarachnoid hemorrhage clinical decision rules

Answer 23

-patient who seek medical attention in the ED complaining of an acute nontraumatic headache should be evaluated for subarachnoid hemorrhage if they have 1 or more of the following factors:
-40 years or older
-neck pain or stiffness
-witnessed loss of consciousness
-onset during exertion
-thunderclap headache
-limited neck flexion

Question 24

Additional dx testing for exclusion of life threatening causes of acute headache

Answer 24

-ESR (temporal arteritis; endocarditis)
-UA (malignant hypertension; preeclampsia)
-sinus CT (bacterial sinusitis, independently or as a cause of venous sinus thrombosis)

Question 25

optic nerve ultrasonography

Answer 25

-optic nerve sheath diameter sonography
-noninvasive quick method for dx increased intracranial pressure

Question 26

Headache treatment

Answer 26

-ketorolac (oral, nasal, or intramuscular), dihydroergotamine, lasmiditan, ubrogepant, or triptans (oral, nasal, subcutaneous)
-intravenous prochlorperazine + diphenhydramine was more effective for migraine pain relief than intravenous hydromorphone
-no benefit from adding intravenous diphenhydramine to intravenous metoclopramide
-prochlorperazine was superior to ketamine for benign headaches (no signs of serious intracranial pathology)
-sumatriptan less effective as immediate therapy for migraine attacks with aura compared to attacks without aura
-haloperidol (2.5mg) intravenous is good for severe benign headache
-timolol eye drops may be effective in the management of acute migraine pain

Question 27

migraine aura

Question 28

beta blockers

Answer 28

-used for migraine prevention
-not treatment

Question 29

oral corticosteriods

Answer 29

-prevent rebound headache after ED discharge
-oral dexamethasone showed to be more effective in one study
-parenteral morphine and hydromorphone should be avoided as first line therapy

Question 30

subanesthetic ketamine infusions

Answer 30

-beneficial for chronic migraines and new daily persistent headaches that do not respond to other aggressive treatments

Question 31

Nerve treatment

Answer 31

-peripheral nerve blocks in older adults
-surgical decompression of peripheral cranial and spinal nerves at trigger sites
-noninvasive vagus nerve stimulation treats migraine and cluster headaches
-peripheral nerve blocks for treatment refractory is effective in pregnancy

Question 32

calcitonin gene related peptide antagonists

Answer 32

-“gepants”
-rimegepant
-atogepant
-monoclonal antibodies (erenumab, fremaezumab, galcanezumab)
-prevent migraines
-ubrogepant and rimegepants have been approved for acute treatment of migraineg
-galcanezumab acts against cluster headaches
-these are used for people that have contraindications (vascular disease) for triptans (ergot derivatives) which are first line therapy

Question 33

serotonin 5-HT receptor agonists

Answer 33

-“ditans”
-lasmiditan
-approved for acute treatment of migraine with or without aura
-these are used for people that have contraindications (vascular disease) for triptans (ergot derivatives) which are first line therapy

Question 34

Other treatment

Answer 34

-high flow oxygen therapy (older patients with cluster headaches)
-regular exercise
-amantadine is effective but can cause adverse effects
-neostigimine and atropine
-ginger

Question 35

treating migraine in pregnant women

Answer 35

-opioids
-butalbital
-low teratogenic risk treatment- intravenous fluid boluses, triptans, nerve blocks
-not well studied

Question 36

When to refer

Answer 36

-frequent migraines not responsive to standard therapy
-migraines with atypical features
-chronic daily headaches due to medication overuse
-gone through all the management -> neurology

Question 37

when to admit

Answer 37

-need for repeated doses of parenteral pain medication
-to facilitate an expedited workup requiring a sequence of neuroimaging and procedures
-to monitor for progression of symptoms and to obtain neurologic consultation when the initial emergency department workup is nonconclusive
-pain severe enough to impair activities of daily living or impede follow up appointments or consultations
-patients with subarachnoid hemorrhage, intracranial mass, or meningitis