HEADACHE

Question 1

MANAGEMENT

Answer 1

VITAL SIGNS
Pay attention to:
fever
elevated blood pressure
cushing’s reflex (hypertension, bradycardia and irregular respirations)

MANAGEMENT: MIGRAINE COCKTAIL
1 L bolus NS
10 mg Metaclopramide IV
25 mg diphenhydramine IV
10 mg ketorolac IV or IM
10 mg dexamethasone IV
1 g Acetaminophen PO
Haloperidol or droperidol 1.25-5 mg IV / IM for intractable nausea/vomiting,

INVESTIGATIONS
+/-CBC
+/-CRP
+/-Blood Cultures
+/-CT Head
+/-LP if CT Head Negative (>6h from onset) but strong suspicion for SAH

INDICATIONS FOR NEUROIMAGING
Patients with neurological findings including change in mental status
Patients with new sudden-onset severe headache
HIV-positive patients with a new type of headache
Patients older than 50 with a new type of headache

Question 2

DOCUMENTATION

Answer 2

HISTORY

Systemic: Fevers, Chills, Weight Loss, Vomiting; Hx of HIV, Immunocompromised, Cancer

Neurological Symptoms: Confusion, Change in Mental Status, Vision Change, Loss of Conciousness, Seizures, FND / Asymmetric Reflex, Slurred Speech, Vertigo

Onset: Acute, sudden or split second “thunderclap”

Older Patient: > 50 y with new or progressive headache

Previous Headache: first headache or different (change in attack frequency, severity or clinical features)

Trauma

PHYSICAL EXAM
Temperature
Blood Pressure
GCS
Pupilary Response
+/- Visual Acuity
Fundoscopy
Complete Neurological Exam
FND 3x PPV for Intracranial Abnormality
HEENT
Meningeal Irritation Maneuvers
Lay patient flat, no pillows
Lift head, hold for 10 seconds to examin for neck stiffness
Jolt accentuation (Sn 97% Sp 60%)
Brudzinski (Sn 97%)
Kernig’s (Sn 57%)

RED FLAGS: SNOOP2

Systemic: fever, chills, weight loss, worse wiht valsalva, HIV / Immunocompromised, CA (Fever, neck pain, or AMS is present in 99-100% of patients with meningitis; abscence of all three is reassuring)

Neuro Symptoms: confusion, AMS, vision change, papilledema, seiaure, Visual Field Defect, FND, seizure (abnormal finding on neurological exam triples likelihood of of positive finding on neuroimaging)

Onset: sudden / abrupt / split second / worst headache of life (90% of SAH will be sudden onset and severe, 30% will lateralize to a side)

Older patient: new onset or progressive > 50 (patients older than 50 are found to have a pathalogical finding 6% of the time, rate increases to 11% in patients older than 75)

Previous Headahce Hx: First Headache OR Different H/A, Worsening over time / Change in severity / Worse in the am (↑ICP)

Pregnant / Post Partum

CALCULATE
Ottawa Subarachnoid Hemorrhage Rule
100% Sensitive, 15.3% Specific

Question 3

DDx: CRITICAL DIAGNOSIS

Answer 3

BLEEDING:
Subarachnoid Hemorrhage
Intracerebral Hemorrhage
Intracranial Hematoma:
-Epidural Hematoma
-Subdural Hematoma
Pituitary Apoplexy

INFECTIOUS
Bacterial Meningitis
Viral Encephalitis
Giant Cell Arteritis

TOXIC / METABOLIC
Carbon Monoxide Poisoning

VASCULAR:
Cerebral Artery Dissection:
-VAD
-CAD
Giant Cell Arteritis
Central Venous Thrombosis
Reversible Cerebral Vasoconstriction Syndrome
Posterior Reversible Encephalopathy Syndrome (PRES)

OCULAR:
Acute angle closure glaucoma
Idiopathic Intracranial Hypertension

OBGYN
Pre-Eclampsia

Question 4

DDX: PRIMARY HEADACHE

Answer 4

Tension
Migraine
Cluster

Question 5

DDx: FEVER AND HEADACHE

Answer 5

Meningitis
Brain Abscess
Encephalitis

Question 6

DDx: SIGNIFICANTLY ELEVATED BLOOD PRESSURE AND HEADACHE

Answer 6

Intracranial Hemorrhage
Hypertensive Encephalopathy
PRES
Pre-eclampsia in a pregnant patient

Question 7

DDx: IRREGULAT RESPIRATIONS, BRADYCARDIA, HYPERTENSION AND HEADACHE

Answer 7

Increased Intracranial Pressure:

Intracranial Hemorrhage
Idiopathic Intracranial Hypertension
Cerebral Venous Thrombosis
Stroke