Headache: Difference between revisions
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==Background== | ==Background== | ||
* Opening pressure useful for SAH, cerebral venous thrombosis | |||
* LP is required if suspect SAH | |||
===Red Flags=== | ===Red Flags=== | ||
{{HA red flags}} | {{HA red flags}} | ||
== | ==Clinical Features== | ||
===History=== | ===History=== | ||
* Time to maximal onset | |||
* Location | |||
** Occipital - Cerebellar lesion, muscle spasm, cervical radiculopathy | |||
** Orbital - Optic neuritis, cavernous sinus thrombosis | |||
** Facial - Sinusitis, carotid artery dissection | |||
* Prior headache history | |||
===Physical Exam=== | ===Physical Exam=== | ||
* Scalp and temporal artery palpation | |||
* Sinus tap / transillumination | |||
*[[EBQ: Jolt Test]] | |||
* Neuro exam | |||
{{Jolt Test}} | {{Jolt Test}} | ||
==Differential Diagnosis== | |||
{{Headache DDX}} | |||
==Diagnosis== | |||
===Laboratory Tests=== | ===Laboratory Tests=== | ||
* If suspect [[temporal arteritis]] -> ESR | |||
* If suspect [[meningitis]] -> CSF studies | |||
** Cannot use CBC to rule-out meningitis | |||
** Add India Ink, cryptococcal antigen if suspect AIDS-related infection | |||
* If suspect CO poisoning -> carboxyhemoglobin level | |||
===Imaging=== | ===Imaging=== | ||
* Consider non-contrast head CT in patients with: | |||
** Thunderclap headache | |||
** Worst headache | |||
** Different headache from usual | |||
** Meningeal signs | |||
** Headache + intractable vomiting | |||
** New-onset headache in pts with: | |||
*** Age > 50yrs | |||
*** Malignancy | |||
*** HIV | |||
*** Neurological deficits (other than migraine with aura) | |||
** Consider CXR | |||
*** 50% of pts w/ pneumococcal meningitis have e/o PNA on CXR | |||
==Management== | ==Management== | ||
* Migraine | |||
** 1st line: Prochlorperazine (compazine) 10 mg IV (+/- Benadryl) | |||
*** Most effective therapy | |||
** 2nd line: | |||
*** Metoclopramide (Reglan) 10 mg IV | |||
*** DHE (Dihydroergotamine) 1 mg IV (often used with an antiemetic) | |||
**** Contraindications: pregnancy, cardiovascular disease, HTN | |||
*** Triptans | |||
**** Contraindications: cardiovascular disease | |||
** Ketorolac | |||
***Lower doses are shown to be just as effective<ref>Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Pt 2):116S-121S.</ref> | |||
*Dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge | |||
* Cluster | |||
** Oxygen | |||
** Triptans | |||
** DHE (Dihydroergotamine) | |||
** Corticosteroids | |||
** Verapemil | |||
* Tension | |||
** NSAIDs | |||
==See Also== | ==See Also== | ||
| Line 74: | Line 75: | ||
*[[CT Before LP]] | *[[CT Before LP]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Neuro]] | [[Category:Neuro]] | ||
Revision as of 14:49, 4 May 2015
Background
- Opening pressure useful for SAH, cerebral venous thrombosis
- LP is required if suspect SAH
Red Flags
Headache Red Flags
Features
- Sudden onset or accelerating pattern
- Maximum intensity of pain at onset (i.e. "thunderclap")
- Worse with valsalva
- Worse in the morning or at night
- No similar headache in past
- Age >50 yr or <5 yr
- Occipitonuchal headache
- Visual disturbances
- Exertional or postcoital
- Family or personal history of SAH, cerebral aneurysm, or AVM
- Focal neurologic signs
- Diastolic BP >120
- Papilledema
- Jaw claudication
Clinical Context
Headache in setting of:
- Infection
- Cancer
- Immunosuppression
- Seizure
- Syncope
- Trauma
- Altered mental status
- Systemic illness (fever, stiff neck, rash)
- Nausea/vomiting
- Patient on anticoagulation, steroids, NSAIDs, antiplatelet
Clinical Features
History
- Time to maximal onset
- Location
- Occipital - Cerebellar lesion, muscle spasm, cervical radiculopathy
- Orbital - Optic neuritis, cavernous sinus thrombosis
- Facial - Sinusitis, carotid artery dissection
- Prior headache history
Physical Exam
- Scalp and temporal artery palpation
- Sinus tap / transillumination
- EBQ: Jolt Test
- Neuro exam
Jolt Test
- Horizontal rotation of the head at frequency of 2 rotations/second - exacerbation of pre-existing headache is positive test.
- Although a 1991 study[1] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity[2][3]. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% Sn
Differential Diagnosis
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Mild traumatic brain injury
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Diagnosis
Laboratory Tests
- If suspect temporal arteritis -> ESR
- If suspect meningitis -> CSF studies
- Cannot use CBC to rule-out meningitis
- Add India Ink, cryptococcal antigen if suspect AIDS-related infection
- If suspect CO poisoning -> carboxyhemoglobin level
Imaging
- Consider non-contrast head CT in patients with:
- Thunderclap headache
- Worst headache
- Different headache from usual
- Meningeal signs
- Headache + intractable vomiting
- New-onset headache in pts with:
- Age > 50yrs
- Malignancy
- HIV
- Neurological deficits (other than migraine with aura)
- Consider CXR
- 50% of pts w/ pneumococcal meningitis have e/o PNA on CXR
Management
- Migraine
- 1st line: Prochlorperazine (compazine) 10 mg IV (+/- Benadryl)
- Most effective therapy
- 2nd line:
- Metoclopramide (Reglan) 10 mg IV
- DHE (Dihydroergotamine) 1 mg IV (often used with an antiemetic)
- Contraindications: pregnancy, cardiovascular disease, HTN
- Triptans
- Contraindications: cardiovascular disease
- Ketorolac
- Lower doses are shown to be just as effective[4]
- 1st line: Prochlorperazine (compazine) 10 mg IV (+/- Benadryl)
- Dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge
- Cluster
- Oxygen
- Triptans
- DHE (Dihydroergotamine)
- Corticosteroids
- Verapemil
- Tension
- NSAIDs
See Also
References
- ↑ Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
- ↑ Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
- ↑ Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8
- ↑ Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Pt 2):116S-121S.