Lecture 4: Headaches in the ED Flashcards
Red Flags in History for ED pt presenting with HA
- Age < 5 or > 50 with new/worsening HA
- Sudden onset thunderclap (Cerebral aneurysm)
- Sudden onset with exertion (SAH, Arterial dissection)
- Fever with HA onset (meningitis)
- Different quality HA
- Usage of bloodthinners (risk of hemorrhage)
- Recent ABX use (may lessen clinical presentation)
Sudden varies, dependent on condition.
Sudden for thunderclap = seconds!
What is considered analgesic overuse when it comes to HAs?
> 10 times a month = risk of rebound HA
What illegal substances can increase risk of hemorrhage in HAs?
- Cocaine
- Amphetamine
- Methamphetamine
What combination on PE might suggest meningitis?
- HA (esp if it persists despite control of fever)
- Fever
- Neck stiffness
- AMS
What fundoscopic finding suggests increased ICP?
Optic desk papilledema = increase ICP
Acute angle closure glaucoma
What might meningismus suggest?
- Infection
- Hemorrhage
What should ALWAYS BE PERFORMED for a patient with HA?
Neurologic exam
Must do CN exam, motor, sensation, gait, DTRs
What associated conditions are concerning with presence of HA?
- Pregnancy
- SLE
- Behcets
- Vasculitis
- Sarcoidosis
- Cancer
Immunosuppressed patients. Consider infection.
What labs are recommended for a high risk pt presenting with HA?
- CBC w/ blood cultures (suspected infection)
- CMP
- Coag panel (suspected bleed or need for LP)
- ESR/CRP (temporal arteritis)
- hCG
When is non-con head CT indicated for HA eval?
- Abnormal neurologic exam
- New/severe HA of sudden onset
- HIV+ with new HA
- Concerned for increased ICP in pt requiring an LP
Indication for LP in evaluation of ED pt with HA
- Meningitis
- Encephalitis
- Intracranial hypotension
- Pseudotumor cerebri
- SAH (if CT was neg but still sus)
CT scan is reliable within 6 hrs of hemorrhage for SAH
MCC of people presenting to ED with HA
Primary HAs: Migraine, cluster, tension
Migraine presentation
- Slow onset, over 72h usually
- MC aura types are lightheaded or visual changes
- unilateral throbbing/pulsatile
- Worsens with physical activity
- N/V, photophobia, phonophobia
MC overall
Migraine Management in the ED
- Analgesic + antiemetic + antihistamine = first line
- Ketorolac + prochlorperazine + diphenhydramine
- Dexamethasone used to reduce risk of recurrence
OK to use metoclopramide too instead.
When are triptans indicated in migraine management in ED?
- No usage prior to arrival.
- CI in pregnancy, CAD, uncontrolled HTN, or CVD
Causes vasoconstriction. Sumatriptan SC or IN.
When are ergot derivatives indicated in migraine management?
- Requires pretx with antiemetic +/- antihistamine
- CI in HTN, IHD, PAD, Pregnancy
DHE4 + metoclopramide +/- diphenhydramine
Management of a pregnant pt with migraine in the ED
- Acetaminophen, Opioids, metoclopramide, corticosteroids
- NSAIDs ok in 1st and 2nd trimesters.
- CI: Triptans, ergotamines, caffeine (Excedrin)
Prevention of migraines post ED tx
- Sumatriptan
- Midrin
Take triptan as soon as pain begins.
Presentation of cluster HA in the ED
- unilateral, excruciating pain
- Pain lasts 12min-180min w/o tx
- Ipsilateral symptoms: lacrimation, conjunctival infection, nasal congestion, edema, sweating
- Recurring daily for > week and remitting for 4+ weeks
- Can be precipitated by ETOH or vasodilators
- Normal neuro
Often located periorbital.
Management of cluster HA in ED
- High flow O2 12LPM via NRB
- Sumatriptan if O2 doesn’t resolve
- Last resort: IN lidocaine, oral ergotamine/caffeine, IV DHE 45
Transitional therapy for cluster HA in ED
- Tapered prednisone over 2wks
- Naratriptan BID
- Ergotamine QHS or BID
F/u with neurology afterwards.
Presentation of tension HA in ED
- Gradual onset
- Diffuse, band-like, vise-like (occipital/frontal)
- Duration: Hours to days
- Mild nausea and photophobia
- Prior: Tension, stress, fatigue
- Normal neuro
Management of tension HA in ED
- NSAIDs/non-opioid analgesic +/- caffeine +/- antiemetic/sedative
- Muscle relaxant if muscle tension noted (only take at night due to sedative effects)
PCP f/u
Ketorolac + compazine/reglan + diphenhydramine
Excedrin OTC for OP use
Take medication as soon as you start feeling pain!
Presentation of brain tumor
- Mild HA, deep aching in nature
- Early on: no focal neuro deficits, HA increasing in frequency/duration CLASSIC
- Later: constant pain, focal neuro deficits
- Worsens upon awakening and with valsalva
What can confirm dx of brain tumor in the ED?
CT scan with con or MRI if available
Management of brain tumor in ED
- Neurosurg consult for large, symptomatic, signs of increased ICP, or impending herniation
- IV glucorticoids (dexamethasone) to reduce cerebral edema
- secondary Antiseizure agent (keppra, topa, lamo, VPA, lacosamide)
- Secure airway if herniation is impending on imaging
Only use secondary if a seizure occurs.
Presentation of post-trauma HA/post concussive syndrome
- Hx of Head injury
- Variable onset of pain
- Non-specific HA (similar to tension or migraine)
- Fatigue, dizziness, vertigo, insomnia, personality changes, etc
Evaluation of post-traumatic headache
CT w/o con if no previous evaluation yet
Management of post-traumatic HA
- Simple = d/c home and f/u with PCP. Usage of nonopiate analgesics or antiemetics
- Avoid activity that could lead to second injury or worsen symptoms.
- Need to gradually return to baseline physical activity
Main characteristics of Idiopathic intracranial HTN/pseudotumor cerebri
Syndrome characterized by
- Papilledema
- Increased ICP
- Normal/small-sized ventricles on imaging
Presentation of Idiopathic Intracranial HTN
- HEADACHE
- Transient visual obscurations
- Pulsatile tinnitus
- Scotoma/scintillations
- Back pain
- Retrobulbar pain
- Diplopia
- Sustained visual loss, which can become permanent
In order of frequency!
PE will show papilledema, visual field loss, and 6th CN palsy.
How does 6th CN palsy present?
Loss of lateral gaze
Dx of Idiopathic Intracranial HTN
- CT scan of brain w/o con = normal
- LP with opening presure > 25cm h2o for adults or 28 in children.
- LP with normal CSF
Must educate pt to avoid valsalva during LP opening
Opening pressure must be performed in lateral decubitus with knees extended!
Managment of Idiopathic Intracranial HTN
- Preserve vision
- Remove CSF until opening pressure = 10-20 cm H2O. 1mL CSF = 1 cm H2O
- Oral acetazolamide +/- thiazide
- If a new Dx = admit
- If old Dx = consult neuro
Acetazolamide = reduction of CSF production
Avoid serial LPs
Presentation of PDPH/intracranial HYPOtension
- Recent hx of LP (MC etiology)
- 24-48h of post-LP
- Bifrontal/occipital
- Worse in upright position, improving in supine
- Auditory, visual, N/V, neck stiffness, LBP, vertigo, dizziness
Leakage of CSF and absorption into surrounding tissue.
Dx of post-dural puncture HA (PDPH)/intracranial hypotension
- Avoid repeating LP.
- If LP is repeated, opening pressure will be very low at < 6cm H2O
- No need for MRI/CT, but it will show diffuse enhancement of the meninges
WikEM says dx is clinical if it was post-LP.
Spontaneous intracranial hypotension needs LP or MRI/CT
Management of PDPH
- Recumbent position for a day
- IVF
- Non-opiate analgesics +/- caffeine
- Consult anesthesiology for need for epidural blood patch
Injection of pt’s blood over opening to clot.
MC ways for brain abscess to form
- Hematogenous spread
- Direct contiguous infection
- Direct seeding by neurosurgery
- Penetrating trauma
Presentation of brain abscess
- HA
- Focal neurologic deficits
- Fever
- Seizure
- S/S of increased ICP
Similar to meningitis?
Workup for a Brain abscess
- CT or MRI brain w/ con is diagnostic
- CBC (leukocytosis)
- CMP (end organ function)
- CRP/ESR elevated in 2/3 of pts
- Blood cultures 2x before first abx
Avoid LP
Management of brain abscess
- Odontogenic = PCN G (rocephin + metro)
- Post-neuro procedure: vanco + cefatzidime
- Anything else: Cefotaxmine + metro
- Steroids only if significant peri-abscess edema w/ associated mass effect and increased ICP
- Need neurosurg to consider aspiration
Based on suspected source
Steroids will dissolve abscess wall!!!!!!!!
MC location for spinal epidural abscess
- Thoracic
- Lumbar
MCC of spinal epidural abscess
Hematogenous spread from soft tissue (MC S. aureus), urine, or respiratory
Risk factors for spinal epidural abscess
- IVDU
- Immunosuppressed
- Prior spinal procedure
Presentation of spinal epidural abscess
- Early: Back pain, fever, spinal tenderness
- Later: Radicular pain, hyperreflexia, nuchal rigidity
- Progressive neuro deficits (Cauda Equina)
Cauda Equina Mnemonic
- Saddle anesthesia
- Pain (lower back/lower limbs)
- Incontinence (stool/urine)
- Numbness (groin/legs)
- Emergency (surgery)
SPINE
Check rectal tone, motor weakness, and perineal sensation
Dx of spinal epidural abscess
- MRI w/ con of spine (CT if no MRI available)
- CBC (Leukocytosis in most)
- Elevated ESR/CRP
- Blood cultures
LP is CI if epidural abscess is suspected
Management of spinal epidural abscess
- Empiric ABX: Vanco + ceftazidime (same as post-neuro brain abscess)
- Consult neurosurg
