Headache in the ED Flashcards
Basic pathway for H/A workup: Starts w/ CC of headache…
- Alarms: evidence of serious HA disorder by H&P?
- Yes: work-up to identify/exclude secondary HA etiology
- No: dx of primary HA disorder?
- Yes: tx primary HA
- No: consider work-up for secondary HA
Pain-sensitive cranial structures =
- Venous sinuses w/ afferent veins
- Arteries at base of brain and their major branches
- Arteries of the Dura
- Dura near base of brain and large arteries
- All extracranial structures
Pain-insensitive cranial structures
Brain parenchyma
Ependyma
Choroid
Pia
Arachnoid
Dura over convexity
Skull
Potential mechanisms of HA development:
Traction on major intracranial vessels
Distension/dilation of intracranial arteries
Inflammation near pain sensitive structures
Direct pressure on cranial or cervical nerves
Sustained contraction of scalp or neck muscles
Stimulation from disease of eye, ear, nose, or sinuses
Etiologies of primary vs secondary H/A:
Main primary and secondary H/A etiologies seen in the ED specifically:
Primary: tension (69%), migraine (15%), cold stimulus HA (15%), cluster (0.1%)
Secondary: hangover (72%), fever (63%), metabolic disorder (22%), nose/sinus (15%), head trauma (4%), eye (3%), vascular (1%)
In the ED
Primary: tension (32%), migraine (22%), cluster (<1%)
_Secondary: _ Miscellaneous illness (33%), no specific dx (7%), CNS tumor (3%), SAH (<1%), meningitis (<1%), temporal arteritis (<1%), subdural hematoma (<1%)
5 main classes of HA:
Tension
Migraine with Aura
Migraine w/o aura
Cluster
Secondary
Describe Tension HA:
Duration 30min to 7 days
At least 2 of: pressing/tightening quality, mild-moderate severity, bilateral, no aggravation by routine physical exam
No more than one of: nausea, photophobia, phonophobia
Associated w/ no vomiting
H&P has no suggestion of underlying organic disease
Describe Migraine w/o Aura
4-72 hours if untreated or unsuccessfully treated
at least 2 of (unilateral location, pulsating quality, moderate-severe intensity, aggravation by physical activity)
associate w/ at least 1 of (N/V, photophobia, or phonophobia)
H&P has no suggestion of underlying organic disease
Describe Migraine w/ aura:
aura defined as at least 3 of (1+ full reversible aura symptoms indicated focal cerebral cortical or brain-stem dysfxn, at least 1 aura symptom developing gradually over >4 minutes or 2+ symptoms occurring in succession, no single aura sx lasting >60min, HA beginning within 60min of aura onset)
H&P has no suggestion of underlying organic disease
Describe Cluster HA:
15-180min untreated
severe unilateral orbital/supraorbital/temporal pain
associated w/ at least 1 (ipsilateral to pain –> conjunctival injection/lacrimation, nasal congestion, rhinorrhea, forehead/facial swelling, miosis/ptosis, eyelid edema),
between 4 to 8 per day
Causes of secondary HA:
intracranial hemorrhage (SAH, intracerebral, subdural/epidural), meningitis/encephalitis
HTN encephalopathy
ischemic stroke
venous sinus thrombosis
hypoxia, hypercarbia, carbon monoxide, temporal arteritis, mass lesions (tumor, abscess, AVM), altitude sickness, metabolic (hypoglycemia, fever, hypothyroid, anemia), glaucoma, pseudotumor cerebrii (benign intracranial HTN), trigeminal neuralgia, post-concussion syndrome, sinusitis w/out complication, post-LP, diet, medications, fatigue, post-exertion, post-coital
Features of ED Eval of HA:
- History:
- first/worst, new/frightening feature, last straw? How did HA start? Previous?
- Pain:
- Where (unilateral/bilateral, frontal/occipital/facial)
- character (pulsatile, steady, shocklike, tightness)
- other symptoms (N/V, LOC, flushing, lacrimation, drop attack, neck stiffness, photophobia, dizziness)
- Precipitating/aggravating factors:
- trauma, exertion, noise, position, foods, drugs, weather, anxiety, menstruation
- Relieving factors:
- darkness, position, pressing on scalp, medication
- Medical history:
- HIV, cancer, HTN, recent procedure (LP), change in meds
- Family hx:
- migraines, SAH
- Environment:
- carbon monoxide
Diagnostic alarms for HA:
onset >50 y.o.
sudden onset
increased freq./severity
new onset w/ risk factors (HIV, cancer)
associated w/ systemic illness
altered MS/FND
papilledema
significant trauma
Treatment
Tension?
Migraine?
Cluster?
Tension: oral analgesia
Migraine: reglan or compazine (10mg IV), serotonin agonists (triptans), narcotics
_Cluster: _ 100% oxygen, intranasal lidocaine, NSAIDS
Diagnostics for HA:
CT
LP
labs based on suspected etiologies
limited role for MRI/MRA/angiography