Headaches Flashcards
What age is concerning for HA?
<5 always a red flag
>50 w/ new HA, different, or worsening
What MOI is worrying for HA?
trauma
What onset is worrying for HA?
Sudden onset in SECONDS not minutes
What is worrying for sudden onset of HA without exertion? With exertion?
Without = cerebral aneurysm (d/t
With = arterial dissection of the carotid or vertebrobasilar circulation
If you have sudden pain with valsalva, what are you worried about?
Mass or lesion in the head d/t more pressure put on it.
Not worried if paired with sinus pressure
When is fever worrying? What do you ask about this?
If not paired with FLS
Ask if the HA or fever came first
Ask about ill contacts
Ask about CO poisoning
Toxin poisoning
What med history to you ask for HA?
What they use for their HA
If they use too much > 10 times = risk of rebound HA
What does corticosteroids concerning for?
Higher risk of infection and being in an immunocompromised state
What can antibiotic use d/t your clinical presentation for HA?
Less severe s/s that may mask a more concerning condition
What does substance use do for HA?
Vasoconstriction leads to not having enough O2 to the brain
Why ask alcohol use for HA?
Falls risk for acute
Increased risk of bleeding d/t damaged liver not producing coag factors
If a patient has a fever + HA, what should you ask?
Infectious ideology
HA + fever + neck stiffness + AMS = high likelihood of meningitis
What do you look at for the eyes for HA?
Optic disk: papilledema = increased ICP
Even if a patient has a normal HA, what do you do?
Neuro exam DOCUMENT THIS and do baseline deficits vs new deficits
Altered mental status
CN exam
Motor - extremity weakness, pronator drift
Deep Tendon Reflex - assess asymmetry or a Babinski
Gait
Coordination testing (finger to nose, heal to shin)
When do you order CBC and blood cultures for HA
suspected infectious etiology
when do you get a COAG panel?
sus of a bleed or need for LP
when do you get ESR/CRP
suspected temporal arteritis
When do you get a a non-contrast CT scan for HA?
Abnormal neurologic examination to include altered mental status, cognitive impairment, or a focal deficit
New, severe headache of sudden onset
HIV-positive patients with presentation of a new headache
Concern for increased ICP in a patient requiring an LP
when are you Concerned for increased ICP in a patient requiring an 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
when do you get a LP for HA?
meningitis, encephalitis, intracranial hypotension, pseudotumor cerebri, subarachnoid hemorrhage (if CT is negative
Characteristics of migraines
slow onset, lasting up to 72 hours
+/- preceding aura
MC auras are lightheadedness and visual changes (scotoma¹ and scintillations²)
Unilateral HA - throbbing, pulsatile in nature
Worse with physical activity
Associated with N/V, photophobia, phonophobia
Patients prefer to lie still in a quiet and dark room
Neuro exam is normal (except photophobia)
1st line therapy for migraine in ER
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)
in that order
Why do you use benadryl with compazine
comedication prevents uncontrollable movements seen in compazine
best way is to take compazine with saline to avoid uncontrollable movements.
if a patient has recurrent HA w/in 3 days for migraine what should you do?
Add corticosteroid (dexamethasone)
If the 1st line therapy does not work for migraine, what can you do?
Triptans
Ergots
NOT for preggos d/t vasoconstrion
What meds can be used for preggo
acetaminophen, opioids, metoclopramide and corticosteroid are safe
NSAIDs safe in 1st and 2nd trimester
what do you do for disposition of a patient w/ migraine?
sumatriptan or midrin
what is a cluster HA?
Unilateral, excruciating pain causing patient to “pace” or “rock back and forth”
orbital, supraorbital, or temporal pain
Pain lasts 12-180 minutes without treatment
Associated ipsilateral 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 > week and remitting for at least 4 weeks
a circadian/circannual pattern is noticed over a period of time
average time between attacks 6 months to 2 years
Attacks can be precipitated by ETOH or vasodilators
Neuro exam is normal
1st line treatment of cluster HA
High flow O2 ¹ (HFO2) x 15 minutes
100% oxygen administered at 12 L/min through a nonrebreathing face mask
2nd line treatment of cluster HA
Sumatriptan if unresolved O2
3rd line treatment of cluster HA
Intranasal lidocaine
ergotamine/caffeine
IV dihydroergotamine (DHE 45)
discharge of cluster HA
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
tension HA characteristic
gradual
bandlike
stressor
normal PE
treatment of tension HA
same treatment as migraine!
NSAID’s or non-opiate analgesic +/- caffeine +/- antiemetic/sedative
ketorolac¹ + Compazine/Reglan² + diphenhydramine³ IV for acute relief in ED¹
when should you take meds for HA
as soon as you feel it
SE of muscle relaxant
sedation
take it at night
what is the presentation of a brain tumor
varity of stages
early = mild HA
as it progresses, HA worsens
Deep, aching pain
migraine or tension-like
no deficits early on but later
pain worse when they first wake up or with bearing down (biggest factor)
n/v, seizures, mental status change
what do you order if you are worried about brain tumor
CT w/ IV contrast
MRI is not easily accessible
Before you get CT with IV contrast, what do you need?
requires a chemistry panel
BUN/Cr
When do you do Emergent neurological/neurosurgical consultation of brain tumor
large, symptomatic tumors
signs of increased ICP
impending herniation
What treatment do you do for brain tumor in ER
IV glucocorticoids to reduce cerebral edema
Dexamethasone
Secondary prevention with antiseizure agent
levetiracetam (Keppra), topiramate (Topamax), lamotrigine (Lamictal), valproic acid, and lacosamide (Vimpat)
Secure airway if signs of impending herniation on imaging
What is post-traumatic HA syndrome?
History of trauma
Non-specific HA
Fatigue/dizziness/vertigo first THEN mental health changes, sensitivity of noise
If a patient comes in with a post-traumatic HA three days after the incident, what do you do?
Order imaging
CT w/out contrast
If a patient comes in with a post-traumatic HA three days after the incident and they already had imaging, what do you do?
Do not need imaging, just give reassurance.
Patient education for post-traumatic HA
Avoid 2ndary injuries (anything that can lead to a 2nd brain injury, which can lead to permanent damages)
Can take weeks to recover
Avoid activities that worsens symptoms
Gradually increase activity
in ER, you will just tell them to f/o with PCP
when do you refer for post-traumatic HA?
ophthalmology if visual complaints
ENT if vertigo is present
neuropsych if prominent mental illness symptoms
MC symptom of Idiopathic Intracranial Hypertension aside from HA
visual changes
s/s of Idiopathic Intracranial Hypertension
Headache
Transient visual obscurations²
Intracranial noises (pulsatile tinnitus)
Scotoma/scintillations
Back pain
Retrobulbar pain (pain behind the eye)
Diplopia
Sustained visual loss (will become permanent if treatment is delayed)
Physical Exam
papilledema, visual field loss, 6th CN (abducens) palsy (loss of lateral gaze)
other CN may be affected but much less commonly
What is a grade 5 optic disk?
severe papiledema
what do you first get for Idiopathic Intracranial Hypertension
CT without contrast d/t so many symptoms.
Normal. However, you are ruling it out
When CT w/out contrast comes back normal for a Idiopathic Intracranial Hypertension, what do you do?
Get a LP
When performing a LP for Idiopathic Intracranial Hypertension, what’s important to remember?
ASSESS FOR OPENING PRESSURE
remember, HTN
Lateral decubitus with knees extended
what should you avoid during LP in order to avoid falsely elevated pressure
avoid valsalva (breath holding/crying) to avoid falsely elevated pressure
What is the opening pressure of Idiopathic Intracranial Hypertension typically?
> 25 cm H2O in adults
28 cmH2O in children
What is CSF of Idiopathic Intracranial Hypertension
normal
Management of Idiopathic Intracranial Hypertension
removal of CSF during LP until target pressure of 10-20 cm H2O is reached
if a patient has an opening pressure of 28, how much do you need to remove?
at least 8 mL to get to 20 cm H2O
Appx. 1 mL of CSF will lower pressure by 1 cm H2O
serial monitoring but don’t use a 2nd LP
if the patient has visual symptoms with Idiopathic Intracranial Hypertension, what do you give?
acetazolamide
Add on a thiazide diuretic if worsening visual symptoms despite max acetazolamide
After being stable and getting to an opening pressure <20 H2O, what is the next step of management for a patient with a NEW dx of Idiopathic Intracranial Hypertension?
Admit for further workup
After being stable and getting to an opening pressure <20 H2O, what is the next step of management for a patient with RECURING dx of Idiopathic Intracranial Hypertension?
consult with neurosurgeon regarding disposition
ensure a quick outpatient f/o
What is the MC history of Intracranial Hypotension
LP because CSF leaks, leading to HA
What is a key factor of Intracranial Hypotension HA?
Laying down helps and upright is worse (working against gravity)
dizziness
neck pain
low back pain from LP
vertigo
What do you avoid in work up Intracranial Hypotension
AVOID LP because opening pressure is < 6 H20 and this is what caused it in the first place
diagnosis based on history
Although MRI/CT is not required in post-dural puncture / Intracranial Hypotension, what would it show and why?
diffuse enhancement of the meninges
we can see because there is not a lot of CSF
Initial treatment of Intracranial Hypotension
symptomatic:
lay flat
IV fluids to build up CSF
tylenol (non-opiate treatments)
If a patient does not have improvement w/in one week of Initial treatment of Intracranial Hypotension, what do you do?
Consult anesthesiology to determine the need for epidural blood patch to create a clot
What is the MOA 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
MC way to get a brain abscess
blood travel from teeth
MC findings of brain abscess
HA
Focal neurologic deficits
Fever
also can see
Seizure
S/S of increased ICP
papilledema, N/V, change in LOC, confusion
What is the workup for brain abscess?
CT or MRI brain - both with contrast is diagnostic
CBC - elevated WBC
CMP - assess end-organ function
Inflammatory markers (CRP, ESR)
elevated in ⅔ of patients
Blood cultures x 2 - before first abx dose
what should you avoid in a brain abscess?
LP - because it could lead to herniation
treatment of brain abscess with odontogenic source
IV PCN G (alt. ceftriaxone PLUS metronidazole)
neuro for aspiration typically
treatment of brain abscess with Post-neurologic source
vancomycin PLUS ceftazidime
neuro for aspiration typically
treatment of brain abscess without tooth or brain source
Cefotaxime (alt. ceftriaxone) PLUS metronidazole 500 milligrams IV every 6 h
neuro for aspiration typically
When do you use steroids for brain abscess
ONLY IF significant peri-abscess edema with associated mass effect (shift of brain structure to one side) and increased ICP
want to decrease herniation
What does steroids due to an abscess?
It can break it down. so you gotta be careful
Spinal epidural abscess etiology
Hematogenous spread from soft tissue (S. aureus - MC), urine or respiratory source
RF of spinal epidural abscess
IV drug use
Immunosuppression
Spinal procedure
MC location of spinal epidural abscess
thoracic and lumbar
s/s of spinal epidural abscess
Back pain + fever (worried if these two)
spinal tenderness to percussion
Cauda equina symptom progression
can happen after spinal epidural abscess
Retention at first followed by incontence, motor weakness, and then paralysis (saddle anesthesia)
over inner thighs
Diagnostic of spinal epidural abscess
MRI with contrast of the spine is preferred imaging
Alt. CT with contrast is the alternative if MRI isn’t available
CBC - leukocytosis (60-70% of patients)
Elevated ESR/CRP
Blood cultures
What is CI in spinal epidural abscess
LP
Management of spinal epidural abscess
Urgent consult neurosurgery¹
Empiric antibiotics
Indications - unavoidable delay in surgery, signs of neurologic dysfunction or sepsis
Regimen: vancomycin PLUS ceftazidime
