Headache

Pearls

- Opening pressure useful for SAH, cerebral venous thrombosis

- LP is required if suspect SAH

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
• Jolt test (have pt rapidly shake head side to side)
• 100% sensitive for meningitis
• "Most useful adjunctive maneuver for evaluating headache in the presence of fever"
• Neuro exam

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

Treatment

• Migraine
• 1st line: Prochlorperazine (compazine) 10mg IV (+/- benadryl)
• Most effective therapy
• 2nd line:
• Metoclopramide (reglan) 10mg IV
• DHE 1mg IV (often used with an antiemetic)
• Contraindications: pregnancy, cardiovascular disease, HTN
• Triptans
• Contraindications: cardiovascular disease
• Ketorolac
• Cluster
• Oxygen
• Triptans
• DHE
• Corticosteroids
• Verapemil
• Tension
• NSAIDs

Source

EB Medicine, 06/01, vol 3, number 6

Annals 2008:52