Acute Headache Flashcards
Evidence based symptom evaluation
-symptoms clinical epidemiology & disease candidates
-Bayesian principles: likelihood of a specific disease depending on patient demographic, comorbidities, and clinical features
general inquiries for acute headache
- > 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)
Acute headache
-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%)
sentinel headache
-before a subarachnoid hemorrhage
-sudden, intense, persistent
-can be days/weeks before hemorrhage
Migraine therapies
-serotonin receptor antagonists or ketorolac
-diminution of headache in response to therapies does not rule out critical conditions such as subarachnoid hemorrhage or meningitis
COVID-19
-can cause acute headache
-increase migraine frequency
-worsening of chronic migraines
-may increase frequency of cerebral venous thrombosis and cerebral venous sinus thrombosis
Causes of acute headache that require immediate treatment
-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
thunderclap headache
-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
Reasons a headache may need workup
-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
pheochromocytoma
-episodic headache associated with the triad: hypertension, palpitations, and sweats
-suggestive of pheochromocytoma
Dx of headache
-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
acute headache physical examination
-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
Diminished visual acuity
suggestive of glaucoma, temporal arteritis, or optic neuritis
ophthalmoplegia or visual field defects
-may be signs of venous sinus thrombosis, tumor, or aneurysm
afferent pupillary defects
-can be due to intracranial masses or optic neuritis
acute severe hypertensive retinopathy
-headache
-hypertension
-retinal cotton wool spots
-flame hemorrhages
-disk swelling
horner syndrome
-ipsilateral ptosis and miosis
-ipsilateral ptosis, miosis, and acute headache may signify carotid artery dissection
elevated intracranial pressure
-papilledema or absent retinal venous pulsations
-neuroimaging is to be done prior to lumbar puncture
Noncontrast head CT
-excludes intracranial hypertension with impending herniation, intracranial hemorrhage, and many types of intracranial masses
contrast head CT
-ordered only after a normal noncontrast head CT
Lumbar puncture
-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
Angiography
-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
Ottawa subarachnoid hemorrhage clinical decision rules
-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
Additional dx testing for exclusion of life threatening causes of acute headache
-ESR (temporal arteritis; endocarditis)
-UA (malignant hypertension; preeclampsia)
-sinus CT (bacterial sinusitis, independently or as a cause of venous sinus thrombosis)
