Headache

1
Headache

• Rosens Chapters 17 and 105
• November 9th, 2006
• By George Filiadis

2
Epidemiology

• 85 of the US population had significant
  headaches at least once
• 3-5 of ED visits have as chief complaint
  headache
• 50 accounts for tension headache while only 8
  of headache has a potentially serious cause
• Only 1 of headache in ED have life threatening
  cause(usually subarachnoid hemorrhage)

3
Rapid Assessment and Stabilization

• Airway, Breathing, Circulation and Mental Status
  assessment in all critical patients with
  headache.
• If there is change in mental status accompanied
  by headache, it must be assumed that cerebral
  circulation is compromised
• The main principle of cerebral resuscitation
  focuses on 7 causes lack of substrate (glucose,
  oxygen), cerebral edema, mass lesion
  intracranially, endogenous or exogenous toxins,
  metabolic alterations(fever, seizure), ischemia,
  or elevated intracranial pressure.

4
Pivot Findings in history

• Pattern and onset of pain
• Activity at onset of pain
• History of head trauma
• History of HIV or immunocompromised state
• Character of the pain

• Location of head pain
• Intensity of pain
• Exacerbating or alleviating factors
• Associated symptoms and risk factors
• Prior history of headache

5
Differential Diagnosis

• Subarachnoid hemorrhage
• Shunt Failure
• Migraine
• Tumor/Masses/ Subdural hematoma
• Carbon Monoxide Poisoning, Mountain Sickness
• Temporal Arteritis

• Glaucoma/Sinusitis
• Tension headaches/ Cervical Sprain
• Cluster
• Bacterial Meningitis/ Encephalitis
• Anoxic Headache/ Anemia
• Hypertensive crisis

6
Migraine Headaches

• Accounts for 1 million visits a year in the ED
• Onset is usually in second decade of life
• More prevalent among women
• Historically thought to be due to cerebral
  vasoconstriction and subsequent vasodilatation

• New beliefs indicate that changes in the
  serotonergic activity in midbrain are precursors
  to migraines
• Divided in migraine with and without aura
• Precipitants are nitrates, sleep deprivation,
  alcohol, hormonal changes, stress, chocolate,
  caffeine, oral contraceptives

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Migraine Without Aura (Common Migraine)

• Most common cause of migraine (80)
• A.At least five attacks with the criteria B,C,D,
  and E
• B. Attack lasts 4 to 72 hours with or without
  treatment
• C. Has two of the following unilateral location,
  pulsating quality, and moderate to severe
  intensity, aggravated by activity

• D. During headache associated with
  nausea/vomiting or photophobia/phonophobia
• E. History, physical and diagnostic tests that
  exclude related organic disease

8
Migraine with Aura (Classic Migraine)

• A. At least two attacks that fulfill criterion B
• B.At least three of the four characteristics
  1)one or more reversible aura symptoms
  indicating focal cerebral or brainstem
  dysfunction 2) at least one aura develops
  gradually over more than 4 minutes and no single
  aura lasts longer than 60 minutes
  
  3)headache begins during aura or follows with a
  symptom-free interval of less than 60 minutes
• C. An appropriate history, physical, and
  diagnostic tests that exclude related organic
  disease.

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Clinical Features

• Most common aura is visual a)scintillating
  scotomas b)photopsias c)teichopsias d
  )blurred vision
• Less common auras are somatosensory a)tingling
  or numbness b)motor disturbances c)cogniti
  ve disturbances

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Clinical Features

• Ophthalmoplegic migraine is a rare condition
  associated with paresis of ocular nerves that may
  last days to weeks
• Hemiplegic migraine is characterized by episodic
  hemiparesis or hemiplegia as an aura that is slow
  or marching in progression and lasts 30 to 60
  minutes

• Basilar artery migraine arises with an aura
  referable to brainstem and associated with near
  blindness, dysarthria, tinnitus, vertigo,
  bilateral paresthesias, or altered consciousness
• Status migrainosus persists longer than 72 hours
  and requires pain management

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Treatment-Abortive
12
Treatment-Prophylactic

• More than 2-3 episodes a month, prolonged
  attacks, severe and debilitating b-blockers
  like propanolol calcium channel
  blockers tricyclic antidepressants depakot
  e monoamine oxidase inhibitors

13
New thoughts for treatment of Migraines-Haldol

• Monzilo PH, Nemoto PH.Acute treatment of migraine
  in emergency room comparative study between
  dexamethasone and haloperidol. Arq Neuropsiquitr.
  2004 june62 513-8 -29 patients who met HIS
  criteria for migraine 14 pt received Haldol 5mg
  and 15 pt received decadron 4 mg .
  Conclusion. Pt who received haldol reached 50
  reduction in pain in 30 min, while patients who
  received decadron reached the same level of
  anesthesia at 2 hrs.

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New thoughts for treatment of Migraines-Haldol

• Honkaniemi, Jari, Liimatainen Suvi,
  Rainesalo(2006) Haloperidol in the Acute
  Treatment of Migraine A Randomized,
  Double-Blind, Placebo-Controlled Study. Headache
  The Journal of Head and Face pain. 46 (5),
  781-787 -40 patients were enrolled in a
  double-blind, placebo-controlled study. 80 of
  patients who were fiest treated with haldol
  showed significant relief while 79 of the
  patients treated with placebo first and
  subsequently with haldol felt significant pain
  relief.

15
Cluster Headache

• More common in men
• Associated with several episodes over 24 hrs that
  can last minutes up to 2 hrs
• Clinical features include -unilateral sharp
  stabbing pain in eye -involves the distribution
  of CN V -30 of patients have partial
  Horners -eye is often injected, tearing

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Cluster Headache-Treatment

• High flow oxygen of 7-10 l/min
• Sumatriptan, DHE
• Prednisone tapering dose
• Sphenopalatine nerve anesthesia with intranasal
  cocaine or lidocaine-controversial

17
Tension Headache

• Most common type of headache
• Higher prevalence in middle aged women
• Usual frequency is 5 episodes per month
• Clinical features include -tight, band-like
  discomfort around the head -intensity of pain is
  not severe and thus not debilitating -h
  eadache does not worsen with physical
  activity -coexisting anxiety and depression
  are common

18
Tension headache-Treatment

• Aspirin, acetaminophen, NSAIDs
• Exercise program
• Nonpharmacologic regimen like massage, mediation,
  and biofeedback
• Psychotherapy

19
Brain Tumor

• In elderly, brain tumor is usually metastatic
  from lung or breast carcinoma.
• Primary brain tumor are more common in adults
  younger than 50 years
• HA is caused either by direct pressure on the
  brain or elevated ICP
• Typical presentation is headache that worsens
  over over weeks to months
• HA is usually present on awakening initially,
  then it becomes continuous.

20
Brain Tumor

• HA is often worse with sneezing, bending,
  coughing.
• Diagnostic tools include CT with IV contrast or
  MRI(best test)

21
Subarachnoid Hemorrhage (SAH)

• Extravasation of blood in subarachnoid space
  activates meningeal nocireceptors causing
  occipital pain and meningismus.
• SAH accounts for 10 of all strokes and is most
  common cause of death from a stroke.
• Causes are saccular aneurysms (80), blood
  dyscrasias, arteriovenous malformations, mycotic
  aneurysms, cavernous angiomas.
• Risk factors include increased age,hypertension,
  smoking, excessive alcohol consumption and
  sympathomimetic drugs.

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Subarachnoid Hemorrhage(SAH)

• There is familial association of cerebral
  aneurysms with several diseases
  -autosomal dominant polycystic kidney
  disease -coarctation of the
  aorta -Marfans syndrome -Ehlers-Danlos
  Syndrome type IV
• 1 to 4 of all ED patients with headache have SAH
  with 50 associated morbidity and mortality

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Clinical Features of SAH

• Sudden thunderclap headache
• Can be associated with exertional activities
• Nausea/vomitng-75
• Neck stiffness-25
• Seizures-10

• Meningismus-50
• Subhyloid or retinal hemorrhages
• Oculomotor nerve pulsy with dilated pupil
• Restlessness and altered level of consciousness

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Prognosis

• It depends on neurological status at the time of
  presentation
• Hunt and Hess scale
• Grades I and II have good prognosis
• Grades IV and V have grave prognosis

26
Diagnostic Studies

• Emergent CT scan of head
• CT is greater than 90 sensitive for acute
  bleeding-less than 24 hr
• Sensitivity decreases to 50 by the end of the
  first week

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Diagnostic Studies

• When CT is negative a lumbar puncture should be
  performed
• The CSF should be spun and the supernatant fluid
  should be observed for xanthochromia (develops
  after 12 hrs)
• CSF xanthochromia with negative CT is diagnostic
• Xanthochromia by spectophotometry is more
  sensitive

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Diagnostic Studies

• Patients with persistent bloody CSF without
  xanthochromia should go vascular imaging
• Up to 90 of patients with SAH have cardiac
  arrhythmias or EKG findings suggestive of
  ischemia
• Typical EKG changes include ST-T wave changes, U
  waves, and QT prolongation

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Treatment

• Airway, breathing, circulation and neurosurgical
  consultation.
• Patients with Grade III SAH usually require
  endotracheal intubation
• Nimodipine 60 mg PO or NG to lessen the chance of
  ischemic stroke due to vasospasm
• Anticonvulsants for patients with evident seizure

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Giant Cell Arteritis

• Systemic inflammatory process of small and medium
  size arteries.
• Mean age of onset is 71 years, rare before 50
• Headache is intermittent, worse at night or on
  exposure to cold
• Associated symptoms include jaw claudication,
  fever, anorexia, pain and stiffness in joints aka
  polymyalgia rheumatica

• On exam there is tenderness of temporal artery.
• Its a medical emergency because long term
  sequelae is permanent visual loss.
• Diagnostic tests include ESR, CRP, LFTs, platelet
  count
• Definite diagnosis is by temporal artery biopsy
• Treatment is prednisone 60-120mg daily.

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Carotid and Vertebral Artery Dissection

• Most common cause of stroke in persons younger
  than 45 years.
• Associated with sudden neck movement or trauma
  following neck torsion, chiropractic
  manipulation, coughing, minor falls, MVA.
• The pathologic lesion is an intramural hemorrhage
  in the media of the arterial wall that can be
  subtle in the early phase leading to thrombus
  formation over time with emboli or significant
  enough to occlude the vessel.
• Patients can present with stroke symptoms days to
  years after dissection.

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Carotid artery Dissection

• Classic triad includes unilateral headache,
  ipsilateral partial Horners syndrome, and
  contralateral hemispheric findings like aphasia,
  neglect, visual disturbance or hemiparesis.
• Older age, occlusive disease, stroke on initial
  presentation has worse prognosis
• Diagnosis is via CT angio, MRI/MRA

33
Vertebral Artery Dissection

• Unilateral posterior headache, and neurological
  findings like vertigo, ataxia, diplopia,
  hemiparesis, and unilateral facial weakness,
  tinnitus
• Diagnosis is same as in carotid dissection
• Treatment includes early anticoagulation followed
  by antiplatelet therapy

34
Idiopathic Intracranial Hypertension

• Also known as Pseudotumor Cerebri.
• Commonly seen in young obese women o
• Predisposing factors include anabolic steroids,
  oral contraceptives, tetracyclines, Vitamin A
• Caused by increased brain water content and
  decreased CSF ouflow.

• Most common symptom is generalized headache.
• Eye movement, bending forward or Valsava may
  worsen headache
• On exam patients have papilledema and visual
  defects, including an enlarged blind spot
  followed by loss of peripheral lesion.

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Idiopathic Intracranial Hypertension(IIP)

• Treatment -stop offending med -lower CSF
  production with acetazolomide
  and furosemide. -steroids -repeat
  LPs -ventricular shunt if with impending
  visual loss.

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Posttraumatic Headache(PTHA)

• Estimated that 30-50 of 2 million closed head
  injuries per year develop headache.
• Associated with dizziness, fatigue, insomnia,
  irritability, memory loss, and difficulty with
  concentration.
• Acute PTHA develops hours to days after injury
  and may last up to 8 weeks.

• Chronic PTHA may last from several months to
  years.
• Patients have normal neurological examination and
  imaging
• Treatment for acute PTHA is symptomatic while for
  chronic PTHA, adjunct therapies include
  beta-blockers and antidepressants.

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Acute Glaucoma

• Sudden onset of eye pain radiating to head, ear,
  teeth, and sinuses.
• Visual symptoms include blurriness, halos around
  lights, and scotomas.
• Nausea and Vomiting

• Due to congenital narrowing of the anterior
  chamber angle that leads to elevated intraocular
  pressure (IOP)
• Medications that elevate IOP include mydriatics,
  sympathomimetics

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Acute Glaucoma

• Physical exam shows a red eye with a fixed
  middilated pupil and shallow anterior chamber
  (separates it from cluster HA)
• IOP in the range of 60 to 90 mmHg ( not found in
  iritis)
• Treatment includes topical miotics, b-blockers,
  carbonic anhydrase inhibitors, optho consult

39
Postdural Puncture Headache

• Most common complication following lumbar
  puncture (up to 40)
• Most common in 18 to 30 year old patients
• It can last up to 5 days
• Bilateral throbbing HA that worsens with upright
  position

• Thought to be due to persistent leak of CSF that
  exceeds its production
• Treatment includes rest, fluids, and blood patch,
  caffeine or theophylline for persistent HA

40
Intracranial Infection

• HA is common complaint in meningitis, brain
  abscess, encephalitis or AIDS
• Diagnostic tools include CT of head and LP

41
Hypertensive Headache

• Elevated blood pressure is not as important in HA
  as the rate by which the blood pressure increases
• Nonetheless, HA with severe HTN is well
  documented especially in hypertensive
  encephalopathy
• Treatment is directed at lowering blood pressure
  slowly
• HA may last for days until brain edema has
  resolved

42
Medication-Induced Headache

• Medication use, abuse or withdrawal s the cause.
• Common in patients with chronic headache
  disorders like migraine or tension-type.
• Most common meds include ASA, NSAIDs, Tylenol,
  barbiturate-analgesic combinations, caffeine, and
  ergotamine

• Patients build tolerance to the meds and
  subsequently require higher doses for symptomatic
  relief.
• Treatment includes withdrawal of the overused
  medications

43
Carbon Monoxide Poisoning

• Usually gradual, subtle, dull, nonfocal throbbing
  pain associated with nausea, chest pain.
• Symptoms may wax and wane as patients may enter
  and leave the area of carbon monoxide
• Exposure to engine exhaust, old or defective
  heating systems, most common in winter months.
• Non focal neurological exams.
• Diagnosis is made by elevated carboxyhemoglobin
• Treatment is oxygen

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High Altitude Headache

• Main symptom of Acute Mountain Sickness
• Can occur at altitudes higher than 5000 feet in
  unacclimatized individuals.
• HA is throbbing, located in temporal or occipital
  area and worsens at night or early in the
  morning.
• Treatment includes supplemental oxygen and
  descent to a lower altitude.

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Key Concepts

• HA is a challenging yet common complaint in ED
• Diseases that we cannot afford to miss are SAH,
  CO poisoning, temporal arteritis, bacterial
  meningitis/encephalitis
• Be liberal with use of CT
• Remember CT doesnt rule out SAH-need LP.
• If CT and LP are negative think of temporal
  arteritis if older than 50 years, and CO
  poisoning.
• Dont forget the eyes!