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Emergency Medicine > Lecture 4: Headaches in the ED > Flashcards

Lecture 4: Headaches in the ED Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Red Flags in History for ED pt presenting with HA

A
  • 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!

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2
Q

What is considered analgesic overuse when it comes to HAs?

A

> 10 times a month = risk of rebound HA

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3
Q

What illegal substances can increase risk of hemorrhage in HAs?

A
  • Cocaine
  • Amphetamine
  • Methamphetamine
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4
Q

What combination on PE might suggest meningitis?

A
  • HA (esp if it persists despite control of fever)
  • Fever
  • Neck stiffness
  • AMS
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5
Q

What fundoscopic finding suggests increased ICP?

A

Optic desk papilledema = increase ICP

Acute angle closure glaucoma

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6
Q

What might meningismus suggest?

A
  • Infection
  • Hemorrhage
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7
Q

What should ALWAYS BE PERFORMED for a patient with HA?

A

Neurologic exam

Must do CN exam, motor, sensation, gait, DTRs

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8
Q

What associated conditions are concerning with presence of HA?

A
  • Pregnancy
  • SLE
  • Behcets
  • Vasculitis
  • Sarcoidosis
  • Cancer

Immunosuppressed patients. Consider infection.

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9
Q

What labs are recommended for a high risk pt presenting with HA?

A
  • CBC w/ blood cultures (suspected infection)
  • CMP
  • Coag panel (suspected bleed or need for LP)
  • ESR/CRP (temporal arteritis)
  • hCG
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10
Q

When is non-con head CT indicated for HA eval?

A
  • Abnormal neurologic exam
  • New/severe HA of sudden onset
  • HIV+ with new HA
  • Concerned for increased ICP in pt requiring an LP
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11
Q

Indication for LP in evaluation of ED pt with HA

A
  • 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

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12
Q

MCC of people presenting to ED with HA

A

Primary HAs: Migraine, cluster, tension

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13
Q

Migraine presentation

A
  • 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

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14
Q

Migraine Management in the ED

A
  • Analgesic + antiemetic + antihistamine = first line
  • Ketorolac + prochlorperazine + diphenhydramine
  • Dexamethasone used to reduce risk of recurrence

OK to use metoclopramide too instead.

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15
Q

When are triptans indicated in migraine management in ED?

A
  • No usage prior to arrival.
  • CI in pregnancy, CAD, uncontrolled HTN, or CVD

Causes vasoconstriction. Sumatriptan SC or IN.

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16
Q

When are ergot derivatives indicated in migraine management?

A
  • Requires pretx with antiemetic +/- antihistamine
  • CI in HTN, IHD, PAD, Pregnancy

DHE4 + metoclopramide +/- diphenhydramine

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17
Q

Management of a pregnant pt with migraine in the ED

A
  1. Acetaminophen, Opioids, metoclopramide, corticosteroids
  2. NSAIDs ok in 1st and 2nd trimesters.
  3. CI: Triptans, ergotamines, caffeine (Excedrin)
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18
Q

Prevention of migraines post ED tx

A
  • Sumatriptan
  • Midrin

Take triptan as soon as pain begins.

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19
Q

Presentation of cluster HA in the ED

A
  • 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.

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20
Q

Management of cluster HA in ED

A
  1. High flow O2 12LPM via NRB
  2. Sumatriptan if O2 doesn’t resolve
  3. Last resort: IN lidocaine, oral ergotamine/caffeine, IV DHE 45
21
Q

Transitional therapy for cluster HA in ED

A
  • Tapered prednisone over 2wks
  • Naratriptan BID
  • Ergotamine QHS or BID

F/u with neurology afterwards.

22
Q

Presentation of tension HA in ED

A
  • Gradual onset
  • Diffuse, band-like, vise-like (occipital/frontal)
  • Duration: Hours to days
  • Mild nausea and photophobia
  • Prior: Tension, stress, fatigue
  • Normal neuro
23
Q

Management of tension HA in ED

A
  1. NSAIDs/non-opioid analgesic +/- caffeine +/- antiemetic/sedative
  2. 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!

24
Q

Presentation of brain tumor

A
  • 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
25
Q

What can confirm dx of brain tumor in the ED?

A

CT scan with con or MRI if available

26
Q

Management of brain tumor in ED

A
  • 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.

27
Q

Presentation of post-trauma HA/post concussive syndrome

A
  • Hx of Head injury
  • Variable onset of pain
  • Non-specific HA (similar to tension or migraine)
  • Fatigue, dizziness, vertigo, insomnia, personality changes, etc
27
Q

Evaluation of post-traumatic headache

A

CT w/o con if no previous evaluation yet

28
Q

Management of post-traumatic HA

A
  • 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
29
Q

Main characteristics of Idiopathic intracranial HTN/pseudotumor cerebri

A

Syndrome characterized by

  • Papilledema
  • Increased ICP
  • Normal/small-sized ventricles on imaging
30
Q

Presentation of Idiopathic Intracranial HTN

A
  1. HEADACHE
  2. Transient visual obscurations
  3. Pulsatile tinnitus
  4. Scotoma/scintillations
  5. Back pain
  6. Retrobulbar pain
  7. Diplopia
  8. Sustained visual loss, which can become permanent

In order of frequency!

PE will show papilledema, visual field loss, and 6th CN palsy.

31
Q

How does 6th CN palsy present?

A

Loss of lateral gaze

32
Q

Dx of Idiopathic Intracranial HTN

A
  • 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!

33
Q

Managment of Idiopathic Intracranial HTN

A
  1. Preserve vision
  2. Remove CSF until opening pressure = 10-20 cm H2O. 1mL CSF = 1 cm H2O
  3. Oral acetazolamide +/- thiazide
  4. If a new Dx = admit
  5. If old Dx = consult neuro

Acetazolamide = reduction of CSF production

Avoid serial LPs

34
Q

Presentation of PDPH/intracranial HYPOtension

A
  • 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.

35
Q

Dx of post-dural puncture HA (PDPH)/intracranial hypotension

A
  • 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

36
Q

Management of PDPH

A
  • 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.

37
Q

MC ways for brain abscess to form

A
  • Hematogenous spread
  • Direct contiguous infection
  • Direct seeding by neurosurgery
  • Penetrating trauma
38
Q

Presentation of brain abscess

A
  • HA
  • Focal neurologic deficits
  • Fever
  • Seizure
  • S/S of increased ICP

Similar to meningitis?

39
Q

Workup for a Brain abscess

A
  1. CT or MRI brain w/ con is diagnostic
  2. CBC (leukocytosis)
  3. CMP (end organ function)
  4. CRP/ESR elevated in 2/3 of pts
  5. Blood cultures 2x before first abx

Avoid LP

40
Q

Management of brain abscess

A
  1. Odontogenic = PCN G (rocephin + metro)
  2. Post-neuro procedure: vanco + cefatzidime
  3. Anything else: Cefotaxmine + metro
  4. Steroids only if significant peri-abscess edema w/ associated mass effect and increased ICP
  5. Need neurosurg to consider aspiration

Based on suspected source

Steroids will dissolve abscess wall!!!!!!!!

41
Q

MC location for spinal epidural abscess

A
  • Thoracic
  • Lumbar
42
Q

MCC of spinal epidural abscess

A

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

43
Q

Risk factors for spinal epidural abscess

A
  • IVDU
  • Immunosuppressed
  • Prior spinal procedure
44
Q

Presentation of spinal epidural abscess

A
  • Early: Back pain, fever, spinal tenderness
  • Later: Radicular pain, hyperreflexia, nuchal rigidity
  • Progressive neuro deficits (Cauda Equina)
45
Q

Cauda Equina Mnemonic

A
  • Saddle anesthesia
  • Pain (lower back/lower limbs)
  • Incontinence (stool/urine)
  • Numbness (groin/legs)
  • Emergency (surgery)

SPINE

Check rectal tone, motor weakness, and perineal sensation

46
Q

Dx of spinal epidural abscess

A
  • 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

47
Q

Management of spinal epidural abscess

A
  • Empiric ABX: Vanco + ceftazidime (same as post-neuro brain abscess)
  • Consult neurosurg

Emergency Medicine (29 decks)

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