Tutorial 32 - Acute Headache

Question 1

List the clinical features of a headache that are associated with serious pathologies.
- History: x10
- Physical exam: x6

Answer 1

History: x10
- Rapid and severe at onset
- No similar headaches in the past
- Concomitant infection
- Altered mental status or seizure
- Association with exertion (exercise, sexual intercourse)
- Age >50
- Immunosuppression: HIV, chronic glucocorticoid use
- Visual disturbances
- Pregnancy or post part
- Medications, illicit drugs (anticoagulants, sympathomimetic agents)

Physical exam: x6
- Abnormal vitals
- Neurologic abnormalities
- Decreased LOC
- Meningismus
- Toxic appearance
- Papilledema or other ophthalmologic findings

Question 2

What are the three general categories of dangerous causes of headache that are screened for?

Answer 2

• Infection
• Vascular and bleeding catastrophes
• Intracranial masses

Question 3

A patient presents to the ER with what they describe as the worst headache of their life that had an onset of only a few minutes. Since this headache started, they are now experiencing severe neck pain, and some nausea and vomiting. What is the most likely diagnosis?

Answer 3

• Subarachnoid hemorrhage

Question 4

After how many hours with a negative non-contrast CT brain can you rule out a subarachnoid hemorrhage?

Answer 4

6 hours

Question 5

What CSF analysis values for WBCs and glucose rules in bacterial meningitis?

Answer 5

WBC > 500/uL
Glucose < 2.2 mmol/L

Question 5

What are the indications for a CT prior to an LP? (6)

Answer 5

• Altered mentation
• Focal neurologic signs
• Papilledema
• Seizure within the previous week
• Impaired cellular immunity
• Trauma

Question 6

What are the red flags for a secondary headache?

Answer 6

• Thunderclap onset
• Fever and meningismus
• Papilloedema
• Unexplained focal neurologic signs
• Unusual headache attack precipitants
• Headache onset after age 50

Question 6

A 43 year hold female patient presents to the clinic with a headache that developed when she got home from work. On further history, she reveals that both her and her partner have been getting headaches when they come home for the last few days.

What test should be ordered to rule in/out your diagnosis, and what are you looking for?

Answer 6

Arterial blood gas (ABG) -> carboxyhemoglobin

Question 6

What is the rule out test for subarachnoid hemorrhage?

Answer 6

Absence of RBC or xanthochromia on LP

Question 6

A patient presents to the ER with a headache