Emergent Head Pain

Question 1

what are the 3 questions you ask a patient with a headache?

Answer 1

1. onset = how rapidly did it come on?
2. severity = how bad is the pain?
3. frequency = have you had a similar headache before?

Question 2

what are the 2 emergent periorbital conditions?

Answer 2

orbital cellulitis and giant cell arteritis (GCA)

Question 3

what are the 6 emergent cranial conditions?

Answer 3

aneurysm, subarachnoid hemorrhage, meningitis/encephalitis, malignant hypertension, cavernous sinus thrombosis, tolosa-hunt syndrome and carotid cavernous sinus fistula

Question 4

why is orbital cellulitis life-threatening?

Answer 4

it can spread to the interior of the skull and kill the patient in a matter of days via the superior orbital fissure
needs IV antibiotics

Question 5

what are the symptoms of orbital cellulitis?

Answer 5

eye/adnexa are significantly edematous and hyperemic, mucopurulent discharge, painful to touch and on eye movements
patient is in distress

Question 6

what are the signs and symptoms of GCA?

Answer 6

age >60, elevated sedimentation rate (>50), patient is unwell, fever, jaw claudication, scalp tenderness, weight loss, palpable temporal artery
associated with polymyalgia rheumatica

Question 7

why is GCA an emergency?

Answer 7

once the optic nerve has stroked, it dies within 4 minutes
then the fellow eye has an elevated risk
there is no recovery

Question 8

what is an aneurysm?

Answer 8

a ballooning out of the wall of an artery (typically) or a vein
usually at the circle of willis
causes a headache (severity 9-10) and widespread, sudden onset

Question 9

what are the signs/symptoms for an aneurysm?

Answer 9

CN3 (pupil and EOMs) or CN6 may be involved, may have VA or VF loss, patient is unwell, distressed, NO fever
frequently has neurologic signs and a change in mental status

Question 10

what can cause a subarachnoid hemorrhage?

Answer 10

an aneurysm or head trauma

Question 11

what is the typical/classic case for subarachnoid hemorrhage?

Answer 11

rapid onset, worst headache of their life, pain with head movement/stiff neck, NO fever and positive for other signs of an aneurysm

Question 12

what are the signs of an atypical SAH?

Answer 12

history of recent head trauma, accompanied by nausea, vomiting, syncope, seizures

Question 13

how does meningitis/encephalitis present?

Answer 13

patient is unwell/distressed with a FEVER, stiff neck, neck pain, and pain on head movement
frequently has change in mental status and neurologic changes

Question 14

what is malignant hypertension and what causes it?

Answer 14

rapid rise in BP (160/100)
pain is due to distension of cerebral arteries or traction on bridging vessels
they also have blurred VA, papilledema and change in mental status

Question 15

how do you test CN 2, 3, 4, 6 function?

Answer 15

VA, VF, pupils, ptosis, EOMs

Question 16

how do you check CN 5 function?

Answer 16

touch patients face lightly on mirror-image points within each of 3 dermatomes
ask if pressure was equally felt by patient

Question 17

how do you check CN 7 function?

Answer 17

ask patient to:

raise eyebrows, shut eyes tight, puff out cheeks, grimace/smile

Question 18

how do you check CN 8 function?

Answer 18

make a “white noise” and have patient report when they can hear noise or compare between two ears

Question 19

how do you check CN 12 function (hypoglossal)?

Answer 19

patient sticks out their tongue and holds it straight

abnormal - it will drift to one side

Question 20

how do you test the descending pyramidal motor system?

Answer 20

have patient hold out both arms with their palms facing up
look for rotation of hands (pronator drift) and check arm strength
can also press on shins

Question 21

what are non-specific signs of elevated intracranial pressure?

Answer 21

papilledema, loss of SVP and CN6 palsy