HA and Facial Pain - Exam 1 Flashcards
What in a pt’s hx for would be red flag symptoms for a HA?
less than 5 and older than 50 with NEW and WORSENING HA
sudden onset: cerebral aneurysm rupture
sudden onset with exertion: subarachnoid hemorrhage
different quality of pain when compared to their usual HA symptoms
fever onset in relation to HA onset
on anticoag/antiplatelet: increased risk of hemorrhage
recent abx use because it can result in less severe clinical presentation
What puts a pt at risk for a rebound HA?
frequent use of OTC medications
analgesic overuse > 10 times a month
What does chronic steroids or immunomodulators increase the risk for? What does recent abx use make you think?
risk of infection due to immunocompromised state
recent use may result in a less severe clinical presentation due to partial treatment
What does substance abuse put the pt at a higher risk for?
increase risk of hemorrhage, reversible cerebral vasoconstriction syndrome
aka all the things cause vasoconstriction
What does chronic ETOH abuse increase the pt’s risk for?
increase risk of hemorrhage due to falls, violence, coagulation disorders associated with chronic ETOH abuse
FMHx of aneurysm or sudden death in 1st degree relative increases risk of aneurysm ______
3-5 x if family hx is (+)
What does a persistent HA despite an adequately controlled fever make you think?
red flag for CNS infection
should do meningitis work-up
Elevated BP + AMS + neurologic dysfunction. What am I?
consider hypertensive emergency, preeclampsia/eclampsia
HA plus scalp tenderness. What am I?
HA plus increased ICP. What am I?
temporal arteritis
acute angle closure glaucoma
What does optic disk papilledema indicate?
increased intracranial pressure
What does meningismus indicate?
indicates infection or hemorrhage
What will the pupil present like in a pt with acute angle closure glaucoma?
mid-fixed pupil
From lecture, what are associated conditions with HA that are clinical red flags?
altered mental status
pregnancy or postpreg status
any condition that is currently being treated with immunosuppressants (Lupus, Behcet’s dz, vasculitis, sarcoidosis, cancer)
What labs should you include in your w/u for HA?
CBC, blood culture
CMP
Coag panel
ESR/CRP
hCG
What are the 4 indications for imaging for a pt with a HA?
abnormal neuro exam: AMS, cognitive impairment, focal deficit
new, severe HA of sudden onset
HIV positive with new HA
increased ICP in a pt requiring LP
What are the 6 indications for a CT before preforming LP?
Immunocompromised patient
Hx of CNS disease (mass lesion, stroke or focal infection)
new onset of seizures (within one week of presentation)
papilledema
altered LOC
focal neurologic deficits
What differentials dx should get a LP?
meningitis
encephalitis
intracranial hypotension
pseudotumor cerebri
subarachnoid hemorrhage (if CT is negative)
What is the clinical presentation of a migraine? What will their neuro exam show?
slow onset
+/- preceding aura
UNILATERAL: throbbing, pulsatile
N/V, photophobia, phonophobia
neuro exam is NORMAL
**What is the tx for migraine in the ED setting? What is unique about this administeration?
Analgesic + antiemetic + antihistamine combination
ketorolac (Toradol) 30 mg IV or 60 mg IM (kids 0.5 mg/kg)
prochlorperazine (Compazine) 10 mg IV (kids 0.15 mg/kg)
diphenhydramine (Benadryl) 25 to 50 milligrams IV (kids 1 mg/kg)
inject the prochlorperazine into saline IV then give to pt to decrease the uncontrolled movements that are associated with prochlorperazine
add ______ to migraine regimen to decrease the recurrence of HA within the first 3 days
dexamethasone
What are the 2 alternative migraine medication options in the ED?
triptans and ergot derivatives
When are triptans CI? Why?
pregnancy, CAD, uncontrolled hypertension or CVD
cause severe vasoconstriction
When are ergot derivatives CI? Why?
hypertension, ischemic heart disease, PAD, pregnancy
causes severe vasoconstriction
What is the migraine tx options for a pt who is pregnant? When are NSAIDs safe? ** What medications are CI?
acetaminophen, opioids, metoclopramide and corticosteroid are safe
NSAIDs safe in 1st and 2nd trimester
CI: Triptans, ergotamines, caffeine
What medication should pt’s with migraine be discharged with?
sumatriptan (Imitrex) 25 mg, 50 mg, or 100 mg
Dosing: 1 tab at onset, repeat after 2 hours; max 200 mg/d
What is the clinical presentation of a cluster HA? How long does the pain typically last?
Unilateral, excruciating pain
orbital, supraorbital or temporal pain
same side symptoms: lacrimation, conjunctival injection, nasal congestion/rhinorrhea, ptosis and/or miosis, edema of the eyelid/face, sweating of the forehead/face
recurring attacks daily for greater than 1 week and remitting for at least 4 weeks
Pain lasts 12-180 minutes without treatment
What is the average time between attack for cluster HAs? What are they typically precipitated by? What does their neuro exam reveal?
6 months to 2 years
precipitated by ETOH or vasodilators
neuro exam is NORMAL
What is the tx for cluster HAs? What are the alternative options?
high flow O2 for 15 minutes
then sumatriptan if oxygen is not helpful
alt options:
Intranasal lidocaine
Oral ergotamine/caffeine
IV dihydroergotamine
pt’s with a cluster HA need to be discharged with a follow up with ______. What are the transitional therapy options that can be started in the ED?
neurology!
transitional therapy options:
corticosteroids (prednisone 60–80 mg/d tapered over 2 weeks)
naratriptan (Amerge) 2.5 mg twice daily
ergotamine 2 mg at bedtime or twice daily
What is the presentation of a tension HA? What does their neuro exam reveal?
gradual onset
diffuse, occipital, frontal or bandlike
typically lasting hours or the entire day
nausea or photophobia
neuro exam is NORMAL!
What is the tx for a tension HA? What is an important pt education point?
NSAIDs +/- caffeine +/- antiemetic/sedative
ketorolac + Compazine/Reglan + diphenhydramine IV for acute relief in ED
muscle relaxant but can be sedating to advise to take at night
pt education: take medication as soon as you feel symptoms come on, DON’T WAIT to take meds!!
**What is an important question to ask that will help differentiate between a brain tumor and a different cause of a HA?
Worse upon awakening and with valsalva
What will a brain tumor feel like early in the disease process? What is likely to occur as time passes?
mild/moderate deep aching pain that can be bilateral or unilateral
no focal neurological signs are present
HA increase in frequency and duration over weeks-months (classic history)
What will a brain tumor feel like later on in the disease process?
constant pain
focal neurologic s/s will develop
n/v, seizures, mental status changes
Why is there constant pain present later on in the course of the dz process?
due to CSF flow obstruction occurs or intracranial hypertension develops
What dx test should you order if you suspect a brain tumor? What is the management?
CT scan WITH CONTRAST
management:
emergent! neuro/neurosx eval
IV dexamethasone
IV secondary prevention of antiseizure meds
- levetiracetam (Keppra), topiramate (Topamax), lamotrigine (Lamictal), valproic acid, and lacosamide (Vimpat)
secure an airway!! if s/s of herniation on
What is the timing associated with Post Concussive Syndrome? What will the HA feel like? When should you perform imaging?
pain can be immediate after trauma or onset may be weeks after trauma
non-specific can be similar to tension/migraine presentation
imaging is only needed if they did NOT have imaging on their previous evaluation
What is the management for Post Concussive Syndrome? When do most pts typically improve?
nothing! Uncomplicated cases can be discharged home with simple reassurance, symptomatic therapy and f/u with PCP
improve within 3 months
If medication is needed for Post Concussive Syndrome, what are your 2 best options?
Non-opiate pain relievers and antiemetics
**What are 3 vital pt education points for Post-traumatic Headache/Syndrome?
avoid activity that could lead to second injury while symptomatic (aka no sports, yard work etc etc)
avoid activity that exacerbates symptoms
gradual return to normal activity once symptoms resolve
What are the 3 findings consistent with Idiopathic Intracranial Hypertension? What is usually present on PE?
papilledema, increased ICP (with normal CSF), and normal/small-sized ventricles on imaging
papilledema, visual field loss, 6th CN (abducens) palsy (loss of lateral gaze)
other CN may be affected but much less commonly
What are transient visual obscurations? What dz are they associated with?
blackening or graying out of vision with activity that increases ICP
idiopathic intracranial hypertension
What are scotoma? Scintillations? What dz are they associated with?
scotoma: black spot in visual field
scintillations: flickering lights in visual field
Idiopathic Intracranial Hypertension
What is retrobulbar pain? what are 2 risk factors for Idiopathic Intracranial Hypertension?
pain behind the eye
female and obesity
What are the two diagnostic evaluations that should be ordered in Idiopathic Intracranial Hypertension?
brain CT without contrast: will be NORMAL
LP: opening pressure will be elevated greater than 25cm in adults and greater than 28 in kids
What will the opening pressure be in Idiopathic Intracranial Hypertension for an adult? kid? What will the CSF fluid analysis show? What position should you place the pt in?
elevated opening pressure¹ > 25 cm H2O in adults and > 28 cmH2O in children
CSF fluid is NORMAL
left lateral decubitus
What is the management for Idiopathic Intracranial Hypertension? What is the primary focus of tx?
remove CSF fluid until target pressure of 10-20 cm H2O is reached
if visual symptoms present: oral acetazolamide +/- thiazide diuretic
neurologist/neurosx referral
focus is to preserve vision!!
What is the target opening pressure when treating a pt with Idiopathic Intracranial Hypertension? Why are you giving acetazolamide?
Removal of CSF during LP until target pressure of 10-20 cm
trying to reduce the rate of CSF production
What is the typically presentation of Post-Dural Puncture/Intracranial Hypotension? **What position is the HA worse in?
recent hx of LP within 24-48 hours
HA worse in upright position, improves in supine position
What do you need to order to confirm the dx of Post-Dural Puncture/Intracranial Hypotension?
nothing! dx is based on hx and PE
If imaging is ordered on Post-Dural Puncture/Intracranial Hypotension, what will it show?
diffuse enhancement of the meninges
What is the tx for Post-Dural Puncture/Intracranial Hypotension?
Recumbency (lay flat) for 18–24 hours
IV fluids
Non opiate analgesics +/- caffeine
Most headaches resolve within one week without treatment
Consult anesthesiology to determine the need for epidural blood patch
What are 3 common ways a pt usually gets a brain abscess?
spreads directly from the blood, infection somewhere in the head, recent neurosx or trauma
What is the composition of a brain abscess?
An inflammation of the brain that develops into a central pus-filled cavity surrounded by a layer of granulation tissue and an outer fibrous capsule
What is the clinical presentation of a brain abscess? What are the 3 major ones?
*HA
*Focal neurologic deficits
*Fever
Seizure
S/S of increased ICP
papilledema, N/V, change in LOC, confusion
What needs to be included as part of your w/o for a pt with a brain abscess?
CT/MRI WITH CONTRAST- diagnostic
CBC, CMP, CRP/ESR, blood cultures
When do you need to obtain blood cultures in a pt with a brain abscess? What procedure do you NOT want to do? Why?
Blood cultures x 2 - before first abx dose
avoid LP: due to risk of brain herniation
What is the choice of abx for a brain abscess based on? give the 3 options. When would you want to give steroids?
abx based on the suspected source of the abscess!
Odontogenic source - IV PCN G (alt. ceftriaxone PLUS metronidazole)
Post-neurologic procedure - vancomycin PLUS ceftazidime
All others - Cefotaxime (alt. ceftriaxone) PLUS metronidazole 500 milligrams IV every 6 h
Steroids ONLY IF significant peri-abscess edema with associated mass effect and increased ICP
ADMIT pt and consult neurosx!!!
