Seizures & Headache in ER

Question 1

Immediately after a seizure, the initial
portion of the exam should focus on
checking for injuries, especially to the ____

Answer 1

head or spine
■ Posterior shoulder dislocations can occur
■ Lacerations of the tongue and mouth,
dental fractures, or pulmonary
aspirations are other common sequelae

Question 2

Approach to first time seizure presenting in the ER

Answer 2

● Obtain a CT head without contrast in the ED for patients with a first-ever
seizures (or a change in established seizure pattern) to evaluate for a
structural, anatomic lesion.
First-Time Seizure
“Tintinalli’s Emergency Medicine: A Comprehensive Study Guide,” 8e, Tintinalli.
○ Meningiomas and other mass lesions can
present with a seizure
● Almost 25% of adults with a new-onset seizure
will have visualized pathology on CT or MRI.
● EEG is helpful, but not available in most EDs.
○ Should be scheduled with Neurologist

Question 2

Todd’s Paralysis

Answer 2

A transient focal deficit (usually a unilateral limb)
following a simple or complex focal seizure

Question 3

Guidelines for treatment of a first time seizure

Answer 3

Guidelines do not currently recommend starting anticonvulsants or admitting
to the hospital in the patient with a first-time, unprovoked seizure, as long as
he/she has returned to neurologic baseline.

Question 4

Status Epilepticus

Answer 4

● Status epilepticus is seizure activity that lasts for more than 5 minutes, or
two or more seizures without regaining consciousness between episodes.
● Status epilepticus is a neurologic emergency
and treatment should be initiated in all
patients with continuous seizures lasting
more than 5 mins. Prevent neuronal damage

Question 5

Refractory status epilepticus

Answer 5

persistent seizure activity despite the IV
administration of adequate amounts of two antiepileptic drugs.

Question 6

Headache Syndromes in the ED

Answer 6

● In the ED, the approach to headache focuses on
identifying patients at risk for rapid deterioration,
morbidity, and mortality; rapidly identifying highrisk headache syndromes; and providing
appropriate headache therapy

Question 7

T/F The parenchyma of the brain has no pain sensors

Answer 7

T

Question 8

“Red Flags” for headaches

Answer 8

■ Sudden onset, associated with trauma, or noted with exertion
■ Altered Mental Status (AMS)
■ Seizure
■ Fever
■ Neurologic deficits (including vision changes)
■ Anticoagulant/Antiplatelet medications
■ Immunosuppressants
■ No history of headaches, change in usual headache quality, or
progressive headache worsening over weeks/months
■ Pregnancy or postpregnancy status
■ Lupus or Sarcoidosis
■ Cancer
■ Altered Mental Status, stiff neck, fever, papilledema,
focal neurologic deficits

Question 9

Common “migraine cocktail” that works well:

Answer 9

■ IVFs- 1 L NS
■ IV Phenergan 25 mg or Zofran 4 or 8 mg
■ IV Benadryl 25 mg
■ IV Ketorolac 30 mg
○ Can substitute Reglan 10 mg for Phenergan or Zofran

Question 10

Cluster Headaches ED treatment

Answer 10

○ 100% oxygen administered at 12 L/min for 15 minutes through a
nonrebreather facemask.
○ Sumatriptan 6 mg SC can also be helpful.
○ Discharge with follow up appointment with PCP.

Question 11

Diagnose with at least 3 of the following 5 criteria of Temporal Arteritis:

Answer 11

○ Age at disease onset greater than or equal to 50 years
○ New type of headache
○ Temporal artery abnormality (tender, enlarged, etc.)
○ Elevated Erythrocyte Sedimentation Rate (ESR)
○ Abnormal artery biopsy (can be done after starting Tx)

Question 11

Intracranial Mass Lesions presentation in ED

Answer 11

● Headaches in the setting of a brain tumor occurs secondary to increased intracranial pressure, whether due to CSF obstruction or edema.
● Non-contrast CT head is the initial study of choice in the ED, but may fail to
Dx small lesions. Consult Neurology or Neurosurgery for management.

Question 12

Giant Cell (Temporal) Arteritis management in ED

Answer 12

● If temporal arteritis is diagnosed in the ED,
treatment should be initiated immediately
with high-dose Prednisone (60 mg QD).
● If the patient is stable to discharge home,
an urgent consult with Ophthalmology and
Rheumatology should be arranged.
● There should also be a follow up
appointment with their PCP arranged for
the next day if possible.

Question 13

How do you know if you need to get a (repeat) CT scan for a post-trauma headache?

Answer 13

○ Worsening headache
○ New neurologic deficits
○ Elderly patient or on Warfarin or anticoagulants

Question 14

Spinal Headache

Answer 14

● Also known as a Post-Dural Puncture Headache, this can occur after a patient has an LP.
● The headache classically resolves when the
patient is lying down, but returns each time
the patient sits up

Question 15

Trigeminal Neuralgia

Answer 15

● Trigeminal Neuralgia is a distinctive facial pain syndrome, rather than a headache, but patients often present with a
CC of “head pain.”
● Characterized by unilateral face pain following the sensory distribution of CN 5 (usually maxillary or mandibular, less commonly ophthalmic).

Question 16

Trigeminal Neuralgia treatment

Answer 16

● Carbamazepine is the drug of first choice,
but is often not prescribed by the ED
provider because of the need for follow up.
● Pain medications often do not help with the
pain, which makes treatment challenging.
Trigeminal Neuralgia
● Urgent referral to a Neurologist is indicated
in severe cases, who will start Tx.

Question 17

Spinal headache treatment

Answer 17

● Conservative treatment is appropriate
because of its benign prognosis.
○ Includes bed rest, NSAIDs, APAP, Caffeine
● Aggressive treatment includes a Blood Patch,
which is usually successful.

Question 18

Giant Cell (Temporal) Arteritis

Answer 18

● Inflammatory condition affecting the small and
medium sized intracranial and extracranial vessels.
● Usually affects people over the age of 50 years.
● In addition to a headache, symptoms may include
fatigue, fever, jaw claudication, TIA symptoms, etc.