The Approach to HA in the ER Flashcards
what ages are red flags while obtaining HX of a HA?
< 5 or > 50 y/o with new or worsening HA
what onset are red flags when obtaining a HX of a HA
- Sudden onset “thunderclap” - cerebral aneurysm rupture (seconds)
-
Sudden onset with exertion
- SAH
- arterial dissection of the carotid or vertebrobasilar circulation
Sudden onset with valsalva would indicate what?
intracranial abnormality
how to assess character of HA pain?
- location, pattern, frequency, quality, severity
- same as previous HA’s?
- different quality requires work up as a new-onset HA (red flag)
what associated sx is a red flag when obtaining the HA hx?
Fever
* onset in relation to HA onset
* severity
* suspicion for CNS infection
what ill contacts are possible when obtaining HA hx?
- infectious etiology
- CO poisoning
- toxin exposure
how can rebound HA occur?
Frequency of use of OTC medication
analgesic overuse > 10x a month = risk of rebound HA
what medications are red flags when obtaining HA hx
- Anticoagulants, antiplatelet agents - increased risk of hemorrhage
- Abx - recent use may result in a less severe clinical presentation d/t partial tx
what medication can increase the risk of infection due to immunocompromised state
Chronic steroids, immunomodulatory agents
what social hx components should you consider while taking HA hx?
- Substance abuse - cocaine, amphetamine, methamphetamine
- increase risk of hemorrhage, reversible cerebral vasoconstriction syndrome - Alcohol use
- increase risk of hemorrhage due to falls, violence, coagulation disorders associated with chronic ETOH abuse
what FHx components should you consider when obtaining HA hx?
- FMHx of aneurysm or sudden death in 1st degree relative
- increases risk of aneurysm 3-5 x if family hx is (+) - FMHx of migraine
- 2-4 x more likely to develop migraines
a persistent HA despite an adequately controlled fever is a red flag for?
CNS infection
HA + fever + neck stiffness + AMS = high likelihood of what dx?
meningitis
with Elevated BP + AMS + neurologic dysfunction, what conditions should you consider?
HTN emergency, preeclampsia/eclampsia
tenderness along temporal artery is indicative of?
temporal arteritis
what eye PE finding is a red flag?
Optic disk: papilledema = increased ICP
What ears, neck, sinus PE findings should you find and r/o?
- Ears - look for signs of OM
- Sinus - look for signs of sinusitis
- Neck - meningismus - indicative of infection or hemorrhage
What PE components should you do for a HA complaint?
- scalp
- eye
- ears
- neck
- sinus
- neurologic exam
when performing a neurologic exam, what findings are you looking for?
focal neurologic abnormalities 🚩
- Altered mental status 🚩
- CN exam
- Motor - extremity weakness, pronator drift
- DTR - assess asymmetry or a Babinski
- Gait
- Coordination testing
what symptoms are clinical red flags?
table
- altered mental status
- seizure
- fever
- neurologic sx
- visual changes
what associated conditions are clinical red flags?
- pregnancy or post-preg status
- SLE
- Behcet’s disease
- vasculitis
- sarcoidosis
- cancer
all require immunomodulators - high risk for infection
are diagnostics always needed for HA?
no!
Indicated if pt is at “high risk” for serious underlying etiology
diagnostic labs for HA
- CBC, blood cultures - suspected infectious etiology
- CMP
- Coag panel - suspected bleed or need for LP
- ESR/CRP - suspected temporal arteritis
- hCG - females of reproductive age
Indications for Imaging for HA complaint
- Abnml neuro exam to include altered mental status, cognitive impairment, or a focal deficit
- New, severe HA of sudden onset
- HIV-positive patients with presentation of a new headache
- Concern for increased ICP in a patient requiring an LP
if indicated, what imaging do you get for HA complaint
CT w/o contrast
indications for a CT before a LP
- AMS
- new onset of seizures (within 1 wk)
- Immunocomp
- focal neuro signs
- papilledema
- H/o CNS disease
- Mass lesion, stroke, or focal infection
LP are indicated if differentials include:
- meningitis
- encephalitis
- intracranial hypotension
- pseudotumor cerebri
- subarachnoid hemorrhage (if CT is negative)
a CT is most reliable for a SAH if pt presents within what time?
within 6 hrs
- slow onset, lasting up to 72 hours
- +/- preceding aura
- MC lightheadedness and visual changes (scotoma and scintillations) - 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
migraine
management for migraine
Analgesic + antiemetic + antihistamine
- 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 mg IV (kids 1 mg/kg)
Adding what medication to reduce risk of recurrent headache within first 3 days
corticosteroid - dexamethasone 10-24 mg mg IV/IM
what migraine management is known to cause movement disorders
prochlorperazine (Compazine) - antiemetic
alt management for migraine?
- Triptan: sumatriptan (Imitrex) 6 mg SC (kids 0.1 mg/kg) or 20 mg intranasally
- useful if patient has not pretreated with triptan prior to ED arrival - Ergot derivatives + pretreatment with antiemetic +/-antihistamine
- Ex: Dihydroergotamine (DHE 45) 1 mg IV + metoclopramide +/- diphenhydramine
CI for triptans
CI in pregnancy, CAD, uncontrolled hypertension or CVD
CI for ergot?
CI : HTN, ischemic heart disease, PAD, pregnancy
alt medications for migraine in pregnant pts?
acetaminophen, opioids, metoclopramide and corticosteroid are safe
NSAIDs are safe during pregnancy when?
1st and 2nd trimester only
what management options are CI during pregnancy
Triptans
ergotamine
caffeine
preventative meds for migraines
- Rx: sumatriptan (Imitrex) 25 mg, 50 mg, or 100 mg
- Dosing: 1 tab at onset, repeat after 2 hours; max 200 mg/d - Rx: Midrin
- Dosing: 2 capsules PO at onset of headache, then 1 capsule PO q1hr until HA relieved up to a cumulative dose of 5 capsules/12 hr - Pt Ed on triggers and lifestyle modifications
Unilateral, excruciating pain causing patient to “pace” or “rock back and forth”
Cluster Headache
orbital, supraorbital, or temporal pain
cluster HA Pain lasts how long without treatment?
12-180 minutes
cluster HA would have what associated sx?
ipsilateral sx - lacrimation, conjunctival injection, nasal congestion/rhinorrhea, ptosis and/or miosis, edema of the eyelid/face, sweating of the forehead/face
Neuro exam is normal
how long do pts have cluster HA for?
Recurring attacks daily for > wk and remitting for at least 4 wks
- a circadian/circannual pattern is noticed over a period of time
- avg time between attacks 6 mo - 2 yrs
Cluster HA attacks can be precipitated by ___ or ___
ETOH or vasodilators
management for cluster HA
-
High flow O2 (HFO2) x 15 min
- 100% oxygen administered at 12 L/min through a nonrebreathing face mask - Sumatriptan (Imitrex) - if unresolved w/ O2
Alt options for cluster HA if unresolved with O2 and triptan?
- Intranasal lidocaine
- Oral ergotamine/caffeine
- IV dihydroergotamine (DHE 45)
what is a Cluster HAs disposition?
Discharge home, f/u with neurology for preventative therapy
what Transitional therapies may be started in ED for cluster HAs?
- 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
- Gradual onset of a constant, non-throbbing pain
- Diffuse, occipital, frontal or bandlike
- Lasting hrs or for the entire day
- Associated sx
- N, photophobia (milder < migraine) - Precipitating factors - tension, emotional stress, and fatigue
- Neuro exam is normal
Tension Headache
management/disposition for Tension Headache
-
NSAIDs or non-opiate analgesic +/- caffeine +/- antiemetic/sedative
- ketorolac + Compazine/Reglan + diphenhydramine IV for acute relief in ED
- Aspirin-Acetaminophen-Caffeine (Excedrin) for outpatient use - Muscle relaxant if muscle tension is noted
- Refer to PCP for prophylactic or tx of underlying stress disorder
how do brain tumors present early in disease?
- Pain is intermittent with no focal neurological signs
- HA increase in frequency and duration over weeks-months (classic hx)
how does a brain tumor present later in disease?
- Constant pain - once CSF flow obstruction occurs or intracranial hypertension develops
- focal neurologic s/s
- Pain is mild-moderate in severity
- Deep, aching in nature - bilateral or unilateral
- increased in frequency or constant pain
- Worse upon awakening and with valsalva
- Associated s/s possible - N/V, seizures, mental status change, +/- focal neurological deficit
brain tumor
diagnostic eval for brain tumor
CT scan with IV contrast will confirm dx
MRI is more sensitive but not as readily available in ED
need to have good kidneys
Emergent neurological/neurosurgical consultation indications
- large, symptomatic tumors
- signs of increased ICP
- impending herniation
what medication is given to reduce cerebral edema for brain tumors?
IV glucocorticoids
Secondary prevention with antiseizure agent for brain tumors?
levetiracetam (Keppra), topiramate (Topamax), lamotrigine (Lamictal), valproic acid, and lacosamide (Vimpat)
what management to do if signs of impending herniation on imaging
Secure airway
- H/o head injury
-
Variable onset
- Pain can begin immediately after trauma or onset may be weeks after trauma - Non-specific HA - may be similar to tension/migraine presentations
- Associated sx - fatigue, dizziness, vertigo, insomnia, depression, irritability, anxiety, loss of concentration and memory, personality changes and noise sensitivity
Post-traumatic Headache/Syndrome
AKA: Post Concussive Syndrome is a sequela of traumatic brain injury (TBI).
when is diagnotic work-up needed for a TBI?
CT w/o contrast if recent trauma w/o previous evaluation
tx for Post-traumatic Headache/Syndrome
- Uncomplicated cases can be DC home with simple reassurance, symptomatic therapy and f/u with PCP
- Most pts improve within 3 mo
- F/u with PCP for evaluation of prophylactic therapy
- Non-opiate pain relievers, antiemetics
important pt education for Post-traumatic Headache/Syndrome
- avoid activity that could lead to second injury while symptomatic
- avoid activity that exacerbates sx
- gradual return to normal activity once symptoms resolve
when to refer Post-traumatic Headache/Syndrome
- ophthalmology if visual complaints
- ENT if vertigo is present
- neuropsych if prominent mental illness symptoms
A syndrome characterized by papilledema, increased ICP (with normal CSF), and normal/small-sized ventricles on imaging
Idiopathic Intracranial Hypertension
sx in Idiopathic Intracranial Hypertension
from most frequent to least
- HA
- Transient visual obscurations
- 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)
PE findings of Idiopathic Intracranial Hypertension
- papilledema, visual field loss, 6th CN (abducens) palsy (loss of lateral gaze)
- other CN may be affected but much less commonly
diagnostic evals for Idiopathic Intracranial Hypertension
- CT scan brain without contrast - normal
- Lumbar Puncture - avoid valsalva to avoid falsely elevated pressure; CSF fluid analysis normal
what opening pressure is diagnostic in idiopathic intracranial HTN during LP?
- > 25 cm H2O in adults
- > 28 cmH2O in children
management for idiopathic intracranial HTN
-
Removal of CSF during LP until 10-20 cm H2O is reached
- 1 mL of CSF = 1 cm H2O
- Serial LP’s are controversial - Visual sx - combo of oral acetazolamide
- New dx - admit for further eval and development of long-term management
- Previous dx - discuss with pts neurologist/neurosurgeon regarding disposition
Add what medication if worsening visual sx despite max acetazolamide for idiopathic intracrainal HTN?
thiazide diuretic
presentation of Post-Dural Puncture/Intracranial Hypotension
-
Recent hx of LP - MC etiology
- rarely occurring spontaneously or after head/spine trauma - Onset is usually within 24-48 hours after LP
- Location may be bifrontal, occipital or involving the neck/upper shoulders
- HA worse in upright position, improves in supine position
- Associates sx
- auditory - tinnitus, hearing loss
- vision - diplopia, blurred vision, or photophobia
- N/V
- neck stiffness, low back pain
- vertigo, dizziness
work-up for Post-Dural Puncture/Intracranial Hypotension
-
Avoid repeat LP
- if performed, opening pressure is usually < 6 cm H2O - MRI/CT not needed to make dx but if performed it will confirm showing diffuse enhancement of the meninges
management for Post-Dural Puncture/Intracranial Hypotension
- Recumbency for 18–24 hours
- IV fluids
- Non opiate analgesics +/- caffeine
- Most HA resolve within 1 wk w/o tx
- Consult anesthesiology to determine the need for epidural blood patch
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
brain abscess
how do brain abscesses spread?
hematogenous spread
direct contiguous infection
direct seeding by neurosurgery or penetrating trauma
presentation of brain abscess
- HA
- Focal neurologic deficits
- Fever
- Seizure
- S/S of increased ICP - papilledema, N/V, change in LOC, confusion
work-up for brain abscess?
- DX: CT / MRI brain with contrast
- CBC - elevated WBC
- CMP - assess end-organ function
- Inflammatory markers (CRP, ESR) - elevated in ⅔ of pts
- Blood CX x2 - before first abx dose
management for Odontogenic source brain abscess
IV PCN G (alt. ceftriaxone PLUS metronidazole)
tx for Post-neurologic procedure sourced brain abscess?
vancomycin PLUS ceftazidime
General tx for brain abscess
- Empiric parenteral abx based upon suspected source
All others - Cefotaxime (alt. ceftriaxone) PLUS metronidazole 500 milligrams IV every 6 h - Steroids ONLY IF significant peri-abscess edema with associated mass effect and increased ICP
- Admit and consult neurosurgery for consideration of abscess aspiration
A collection of pyogenic material that accumulates in the epidural space between the dura and vertebral periosteum
Spinal Epidural Abscess
Spinal Epidural Abscess MC occurs where?
thoracic and lumbar spine
MC pathogen of Spinal Epidural Abscess
soft tissue
S. aureus
Hematogenous spread from soft tissue, urine or rsp source
RF for spinal epidural abscess
- IVDU
- Immunosuppression
- Spinal procedure
presentation of spinal epidural abscess
- Early: back pain, fever, spinal tenderness → radicular pain, hyperreflexia, and nuchal rigidity
- Followed by progressive neurologic deficits (cauda equina)
- fecal or urinary incontinence→motor weakness → paralysis
- decreased rectal tone and perineal sensation
diagnostics for 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
Spinal Epidural Abscess: if an epidural abscess is suspected, what procedure is CI?
LP
management for spinal epidural abscess
- Urgent consult neurosurgery
-
Empiric abx:
- Indications - unavoidable delay in surgery, signs of neurologic dysfunction or sepsis
- vancomycin + ceftazidime
