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Emergency Medicine > Headaches > Flashcards

Headaches Flashcards

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1
Q

What age is concerning for HA?

A

<5 always a red flag
>50 w/ new HA, different, or worsening

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2
Q

What MOI is worrying for HA?

A

trauma

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3
Q

What onset is worrying for HA?

A

Sudden onset in SECONDS not minutes

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4
Q

What is worrying for sudden onset of HA without exertion? With exertion?

A

Without = cerebral aneurysm (d/t
With = arterial dissection of the carotid or vertebrobasilar circulation

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5
Q

If you have sudden pain with valsalva, what are you worried about?

A

Mass or lesion in the head d/t more pressure put on it.

Not worried if paired with sinus pressure

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6
Q

When is fever worrying? What do you ask about this?

A

If not paired with FLS
Ask if the HA or fever came first
Ask about ill contacts
Ask about CO poisoning
Toxin poisoning

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7
Q

What med history to you ask for HA?

A

What they use for their HA
If they use too much > 10 times = risk of rebound HA

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8
Q

What does corticosteroids concerning for?

A

Higher risk of infection and being in an immunocompromised state

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9
Q

What can antibiotic use d/t your clinical presentation for HA?

A

Less severe s/s that may mask a more concerning condition

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10
Q

What does substance use do for HA?

A

Vasoconstriction leads to not having enough O2 to the brain

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11
Q

Why ask alcohol use for HA?

A

Falls risk for acute
Increased risk of bleeding d/t damaged liver not producing coag factors

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12
Q

If a patient has a fever + HA, what should you ask?

A

Infectious ideology
HA + fever + neck stiffness + AMS = high likelihood of meningitis

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13
Q

What do you look at for the eyes for HA?

A

Optic disk: papilledema = increased ICP

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14
Q

Even if a patient has a normal HA, what do you do?

A

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)

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15
Q

When do you order CBC and blood cultures for HA

A

suspected infectious etiology

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16
Q

when do you get a COAG panel?

A

sus of a bleed or need for LP

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17
Q

when do you get ESR/CRP

A

suspected temporal arteritis

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18
Q

When do you get a a non-contrast CT scan for HA?

A

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

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19
Q

when are you Concerned for increased ICP in a patient requiring an LP?

A

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

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20
Q

when do you get a LP for HA?

A

meningitis, encephalitis, intracranial hypotension, pseudotumor cerebri, subarachnoid hemorrhage (if CT is negative

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21
Q

Characteristics of migraines

A

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)

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22
Q

1st line therapy for migraine in ER

A

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

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23
Q

Why do you use benadryl with compazine

A

comedication prevents uncontrollable movements seen in compazine

best way is to take compazine with saline to avoid uncontrollable movements.

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24
Q

if a patient has recurrent HA w/in 3 days for migraine what should you do?

A

Add corticosteroid (dexamethasone)

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25
Q

If the 1st line therapy does not work for migraine, what can you do?

A

Triptans
Ergots

NOT for preggos d/t vasoconstrion

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26
Q

What meds can be used for preggo

A

acetaminophen, opioids, metoclopramide and corticosteroid are safe
NSAIDs safe in 1st and 2nd trimester

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27
Q

what do you do for disposition of a patient w/ migraine?

A

sumatriptan or midrin

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28
Q

what is a cluster HA?

A

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

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29
Q

1st line treatment of cluster HA

A

High flow O2 ¹ (HFO2) x 15 minutes
100% oxygen administered at 12 L/min through a nonrebreathing face mask

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30
Q

2nd line treatment of cluster HA

A

Sumatriptan if unresolved O2

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31
Q

3rd line treatment of cluster HA

A

Intranasal lidocaine
ergotamine/caffeine
IV dihydroergotamine (DHE 45)

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32
Q

discharge of cluster HA

A

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

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33
Q

tension HA characteristic

A

gradual
bandlike
stressor
normal PE

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34
Q

treatment of tension HA

A

same treatment as migraine!

NSAID’s or non-opiate analgesic +/- caffeine +/- antiemetic/sedative
ketorolac¹ + Compazine/Reglan² + diphenhydramine³ IV for acute relief in ED¹

35
Q

when should you take meds for HA

A

as soon as you feel it

36
Q

SE of muscle relaxant

A

sedation

take it at night

37
Q

what is the presentation of a brain tumor

A

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

38
Q

what do you order if you are worried about brain tumor

A

CT w/ IV contrast

MRI is not easily accessible

39
Q

Before you get CT with IV contrast, what do you need?

A

requires a chemistry panel
BUN/Cr

40
Q

When do you do Emergent neurological/neurosurgical consultation of brain tumor

A

large, symptomatic tumors
signs of increased ICP
impending herniation

41
Q

What treatment do you do for brain tumor in ER

A

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

42
Q

What is post-traumatic HA syndrome?

A

History of trauma
Non-specific HA
Fatigue/dizziness/vertigo first THEN mental health changes, sensitivity of noise

43
Q

If a patient comes in with a post-traumatic HA three days after the incident, what do you do?

A

Order imaging
CT w/out contrast

44
Q

If a patient comes in with a post-traumatic HA three days after the incident and they already had imaging, what do you do?

A

Do not need imaging, just give reassurance.

45
Q

Patient education for post-traumatic HA

A

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

46
Q

when do you refer for post-traumatic HA?

A

ophthalmology if visual complaints
ENT if vertigo is present
neuropsych if prominent mental illness symptoms

47
Q

MC symptom of Idiopathic Intracranial Hypertension aside from HA

A

visual changes

48
Q

s/s of Idiopathic Intracranial Hypertension

A

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

49
Q

What is a grade 5 optic disk?

A

severe papiledema

50
Q

what do you first get for Idiopathic Intracranial Hypertension

A

CT without contrast d/t so many symptoms.

Normal. However, you are ruling it out

51
Q

When CT w/out contrast comes back normal for a Idiopathic Intracranial Hypertension, what do you do?

A

Get a LP

52
Q

When performing a LP for Idiopathic Intracranial Hypertension, what’s important to remember?

A

ASSESS FOR OPENING PRESSURE

remember, HTN

Lateral decubitus with knees extended

53
Q

what should you avoid during LP in order to avoid falsely elevated pressure

A

avoid valsalva (breath holding/crying) to avoid falsely elevated pressure

54
Q

What is the opening pressure of Idiopathic Intracranial Hypertension typically?

A

> 25 cm H2O in adults
28 cmH2O in children

55
Q

What is CSF of Idiopathic Intracranial Hypertension

A

normal

56
Q

Management of Idiopathic Intracranial Hypertension

A

removal of CSF during LP until target pressure of 10-20 cm H2O is reached

57
Q

if a patient has an opening pressure of 28, how much do you need to remove?

A

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

58
Q

if the patient has visual symptoms with Idiopathic Intracranial Hypertension, what do you give?

A

acetazolamide

Add on a thiazide diuretic if worsening visual symptoms despite max acetazolamide

59
Q

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?

A

Admit for further workup

60
Q

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?

A

consult with neurosurgeon regarding disposition

ensure a quick outpatient f/o

61
Q

What is the MC history of Intracranial Hypotension

A

LP because CSF leaks, leading to HA

62
Q

What is a key factor of Intracranial Hypotension HA?

A

Laying down helps and upright is worse (working against gravity)

dizziness
neck pain
low back pain from LP
vertigo

63
Q

What do you avoid in work up Intracranial Hypotension

A

AVOID LP because opening pressure is < 6 H20 and this is what caused it in the first place

diagnosis based on history

64
Q

Although MRI/CT is not required in post-dural puncture / Intracranial Hypotension, what would it show and why?

A

diffuse enhancement of the meninges

we can see because there is not a lot of CSF

65
Q

Initial treatment of Intracranial Hypotension

A

symptomatic:

lay flat
IV fluids to build up CSF
tylenol (non-opiate treatments)

66
Q

If a patient does not have improvement w/in one week of Initial treatment of Intracranial Hypotension, what do you do?

A

Consult anesthesiology to determine the need for epidural blood patch to create a clot

67
Q

What is the MOA of a brain abscess?

A

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

68
Q

MC way to get a brain abscess

A

blood travel from teeth

69
Q

MC findings of brain abscess

A

HA
Focal neurologic deficits
Fever

also can see

Seizure
S/S of increased ICP
papilledema, N/V, change in LOC, confusion

70
Q

What is the workup for brain abscess?

A

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

71
Q

what should you avoid in a brain abscess?

A

LP - because it could lead to herniation

72
Q

treatment of brain abscess with odontogenic source

A

IV PCN G (alt. ceftriaxone PLUS metronidazole)

neuro for aspiration typically

73
Q

treatment of brain abscess with Post-neurologic source

A

vancomycin PLUS ceftazidime

neuro for aspiration typically

74
Q

treatment of brain abscess without tooth or brain source

A

Cefotaxime (alt. ceftriaxone) PLUS metronidazole 500 milligrams IV every 6 h

neuro for aspiration typically

75
Q

When do you use steroids for brain abscess

A

ONLY IF significant peri-abscess edema with associated mass effect (shift of brain structure to one side) and increased ICP

want to decrease herniation

76
Q

What does steroids due to an abscess?

A

It can break it down. so you gotta be careful

77
Q

Spinal epidural abscess etiology

A

Hematogenous spread from soft tissue (S. aureus - MC), urine or respiratory source

78
Q

RF of spinal epidural abscess

A

IV drug use
Immunosuppression
Spinal procedure

79
Q

MC location of spinal epidural abscess

A

thoracic and lumbar

80
Q

s/s of spinal epidural abscess

A

Back pain + fever (worried if these two)

spinal tenderness to percussion

81
Q

Cauda equina symptom progression

can happen after spinal epidural abscess

A

Retention at first followed by incontence, motor weakness, and then paralysis (saddle anesthesia)

over inner thighs

82
Q

Diagnostic of spinal epidural abscess

A

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

83
Q

What is CI in spinal epidural abscess

A

LP

84
Q

Management of spinal epidural abscess

A

Urgent consult neurosurgery¹

Empiric antibiotics
Indications - unavoidable delay in surgery, signs of neurologic dysfunction or sepsis
Regimen: vancomycin PLUS ceftazidime

Emergency Medicine (14 decks)

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