Headache in the ED

Question 1

Basic pathway for H/A workup: Starts w/ CC of headache…

Answer 1

• 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

Question 2

Pain-sensitive cranial structures =

Answer 2

• 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

Question 3

Pain-insensitive cranial structures

Answer 3

Brain parenchyma

Ependyma

Choroid

Pia

Arachnoid

Dura over convexity

Skull

Question 4

Potential mechanisms of HA development:

Answer 4

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

Question 5

Etiologies of primary vs secondary H/A:

Main primary and secondary H/A etiologies seen in the ED specifically:

Answer 5

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%)

Question 6

5 main classes of HA:

Answer 6

Tension

Migraine with Aura

Migraine w/o aura

Cluster

Secondary

Question 7

Describe Tension HA:

Answer 7

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

Question 8

Describe Migraine w/o Aura

Answer 8

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

Question 9

Describe Migraine w/ aura:

Answer 9

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

Question 10

Describe Cluster HA:

Answer 10

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

Question 11

Causes of secondary HA:

Answer 11

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

Question 12

Features of ED Eval of HA:

Answer 12

• 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

Question 13

Diagnostic alarms for HA:

Answer 13

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

Question 14

Treatment

Tension?

Migraine?

Cluster?

Answer 14

Tension: oral analgesia

Migraine: reglan or compazine (10mg IV), serotonin agonists (triptans), narcotics

_Cluster: _ 100% oxygen, intranasal lidocaine, NSAIDS

Question 15

Diagnostics for HA:

Answer 15

CT

LP

labs based on suspected etiologies

limited role for MRI/MRA/angiography