Transcript Headache Classification

Headache
Benjamin Katz, MD
Case Study
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28yo W c/o sudden onset
posterior headache that awoke
her from sleep. She also c/o
nausea/vomiting and neck
stiffness.
AMPLE: no meds, nkda, no
PMHx, last ate dinner
Case Study
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Vitals: HR 110 BP 180/105 RR 20 sPO2 99
AAOx3, uncomfortable
PERRL, stiff neck
RRR, CTAB
MAEx4, normal sensorium
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Ddx?
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Headache Classification
Critical Secondary
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Vascular
– Subarachnoid
Hemorrhage
– Intraparenchymal
Hemorrhage
– Epidural Hematoma
– Subdural Hematoma
– Stroke
– Cavernous Sinus
thrombosis
– Arteriovenous
Malformation
– Temporal Arteritis
– Carotid or Vertebral
Artery Dissection
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CNS Infection
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Tumor
Pseudotumor Cerebri
Opthalmic
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Glaucoma
Iritis
Optic neuritis
Drug Related
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Meningitis
Encephalitis
Cerebral Abscess
Nitrates
MAOI’s
Alcohol Withdrawal
Toxic
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CO poisioning
Headache Classification
Critical Secondary (cont)
 Endocrine
– Pheochromocytoma
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Reversible Secondary
 Non-CNS Infections
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Metabolic
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Hypoxia
Hypoglycemia
Hypercapnia
High altitude cerebral
edema
– Preeclampsi
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Focal
Systemic
Sinusitis
Odontogenic
Otic
Drug Related
– Chronic Analgesia
use
– MSG
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Post Lumbar Puncture
Headache Classification
Primary Headache Syndromes
 Migraine
 Tension
 Cluster
Migraine
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Onset in teens
5% men, 15-17% women
Peak age 40
Aura: primary neuronal dysfunction:
spreading hypoactivity correlating with
reduced blood flow
Headache: related to activation of
sensory area, release of inflammatory
peptides, increased blood flow
ICHD-2 Migraine without Aura
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5 attacks fulfilling the below
Headache lasting 4-72 hours
At least 2 of
– Unilateral location
– Pulsating quality
– Moderate/severe pain intensisty
– Aggravation by physical activity
Associated with at least 1 of
– Nausea and/or vomiting
– Photophobia and phonophobia
Migraine
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Migraine with aura similar, but
with up to 60 minutes of any of
visual scotoma, hemiparesis or
aphasia
Aura without migraine
Without prior history, diagnosis
of exclusion
Migraine
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Treatment
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Quiet, dark area
IVF for nausea/vomiting
Ergot or triptans
Antiemetics (reglan, phenergan,
keterolac, droperidol, compazine)
– Maintenance (beta-blockers)
Tension Headache (ICDH-2)
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Infrequent episodic TTH
– 10+ episodes less than 1
per month and 12 per
year with the following
– 30 min- 7 days
– 2 of the following
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Bilateral
Non-pulsating pressure
Mild/moderate intensity
Unrelated to activity
– Both of the following
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No nausea or vomiting
Either one of
photophobia or
phonophobia
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Frequent TTH
– >1, <15 per month for 3
months
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Chronic TTH
– >15 per month,
>3months
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Treatment
– NSAIDS first line
– If severe, same as
migraine
Cluster Headache
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Rare, 0.4% population, short without
treatment, secondary to trigeminal nerve
dysfunction
Severe, unilateral, orbital or temporal
pain lasting 15-180 minutes
Associated with conjunctival injection,
lacrimation, nasal congestion, rhinorrhea,
miosis, ptosis
Treatment: high flow O2, ergots, triptans
(NSAIDs for maintenance)
Red Flags for Headache
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Sudden Onset: SAH, AVM or mass lesion
Worsening pattern: Mass, SDH, medication
overuse
Headache with fever, stiff neck or rash:
meningitis, encephalitis, lyme, systemis infection,
collagen vascular disease, arteritis
Focal neuro signs: Mass lesion, AVM, collagen
vascular disease, CVA
Trigger with cough, exertion, valsalva: SAH or
mass
Pregnancy/postpartum: sinus thrombosis, carotid
dissection, pituitary apoplexy
Red Flags Continued
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New Headache in patient with
– Cancer: metastasis
– Lyme disease: meningitis
– HIV: opportunistic Infection,
tumor
Subarachnoid Hemorrhage
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1/10,000 in U.S.
Young, median age 50
50% mortality at 6 months
50% with initially normal exam, vitals,
absence of neck stiffness
Caused by anneurysm or AVM rupture
Diagnosis: CT detects 93% in 24hr, 80%
after 24hr
Treatment: support ABCs, definitive
treatment is coiling or clipping
Intraparenchymal Hemorrhage
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55% report headache at onset of
symptoms
Suspicion if hypertension, known mass,
bleeding diathesis, trauma
Support ABCs
REMO protocol Hypertensive Emergency
if SBP>220, DBP>120
– EKG, IV, O2, monitor
– NTG, metoprolol for chest pain, pulm edema
Epidural Hematoma
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Tear in middle meningeal artery or
rarely dural sinus
Direct trauma with LOC, lucid
interval progressing to coma
Also consider if lethargy, vomiting,
headache, ipsilateral dilated pupil
(herniation)
Subdural Hematoma
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Hematoma between dura mater and
subarachnoid due to tearing of bridging
veins
Consider with history of falls, head
trauma, EtOH, elderly, anticoagulation
Suspect if bruise or scalp lac, lethargy,
vomiting, headache, ipsilateral dilated
pupil
Treatment: support ABCs, definitive
treatment is neurosurgical evacuation
Stroke
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80% ischemic (thrombus, embolus,
hypoperfusion)
Hemorrhagic (IPH, SAH)
– Risk if HTN, elderly, prior CVA, Asian and
Blacks > whites, bleeding diathesis, vascular
malformation, cocaine use
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Consider thrombus if HTN, CAD, DM
Embolus if A-fib, Valve replacement,
recent MI
Stroke
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If h/o TIA with same distribution,
then consider thrombus, if different
distribution consider embolus
Sudden onset suggests hemorrhage
or embolus
Gradual onset suggests thrombus
or hypoperfusion
Assessment
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Level of Consciousness
Vision (fields and eye movement)
Motor (strength, pronator drift)
Cerebellar function (gait, finger to nose,
heel to shin)
Sensation and Neglect
Language
– Dysarthria: inability to articulate
– Aphasia: defect in language processing
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Cranial Nerve
Cincinatti Prehospital Stroke
Scale
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Facial Droop
-Normal: Both sides of face move equally well.
-Abnormal: One side of face doesn’t move as well as
other side.
Arm Drift
-Normal: Both arms move the same or both arms
don’t move at all.
-Abnormal: One arm doesn’t move or one arm drifts
down compared to the other.
Speech (Ask patient to say “The sky is blue in
Cincinatti”)
-Normal: Patient says correct words without slurring
-Abnormal: Patient slurs words, says wrong words or
is unable to speak.
REMO protocol
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Draw a blood sample, check the blood
glucose level, and establish IV access.
If the patient is a diabetic, treat as per
the Diabetic Emergencies Protocol. If
taking an opiate or analgesic
medication, treat as per the Overdose
Protocol.
Monitor the EKG, CNS status and vital
signs every 10 minutes.
Begin transportation and notify the
destination hospital as soon as
possible.
Stroke Therapy
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Important to identify
exact time patient last
had normal exam for
potential thrombolytic
therapy (tPA)
Lysis if >18yo, clinical
diagnosis of ischemic
CVA, onset less than 3
hours
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Exclusion
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minor symptoms
rapid improvement
prior ICH
fs <50 or >400, seizure
GI/GU bleeding within 21
days
recent MI
surgery within 14 days,
sustained SBP>185 or
DBP>110
CVA or head injury
within 90 days
anticoagulant use
thrombocytopenia
Temporal Arteritis
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Autoimmune Vasculitis characterized by
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temporal headache
visual disturbance (amaurosis fugax)
claudication (masseter, temporalis tongue)
Scalp tenderness
Pulsating temporal artery (absent late stage)
Decreased visual acuity
Weakness
Weight loss
Patients >50yo, women>men, 15-30 per 100,000
Treatment with steroids, biopsy for definitive
diagnosis, risk for blindness if untreated
Carotid or Vertebral Dissection
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Characterized by
– Headache
– Vertigo
– Unilateral Horner Syndrome
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Suspect if sudden neck rotation or
extension urgent imaging and
neurosurgery
CNS Infection
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Protect yourself first
– Fever + headache=mask
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Meningitis: inflammation of arachnoid and pia
mater caused by bacteria, virus or fungi
– Headache, stiff neck, fever, chills, photophobia,
confusion, phonophobia, nausea, vomiting, seizures
(more common in children), rash, petechiae,
Brudzinski or Kernig signs
– Bacterial in 400 per 100,000 children, 1-2 per
100,000 adults
– Long term complications of cognitive defects,
epilepsy, hydrocephalus, hearing loss
CNS Infection (cont)
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Infection via subarachnoid space
(encapsulated organisms), also at risk if
head trauma, neurosurgery, immune
suppression
Viral meningitis-- typically less severe
illness: enterovirus, mumps, CMV, HSV,
adenovirus, HIV
Fungal– may be severe, consider if
immunosupressed
Treatment: Support ABCs, treat for
shock/sepsis…definitive therapy is abx
CNS Infections continued
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Viral Encephalitis: infection of brain
parenchyma (arbovirus, HSV, HVZ, EBV,
CMV, Rabies, equine encephalitis, West
Nile)
– New psychiatric sx, cognitive defect, seizures,
movement disorders
– Treatment with antivirals
CNS Infections (cont)
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Brain Abscess: uncommon infection
extending from otitis, hemotogenous or
instrumentation
– Classic fever, headache, focal neuro deficit in
less than one third
– Symptoms from focal and mass effect cause
delayed diagnosis
– Diagnosis with imaging, LP, +/- biopsy
– Treatment: support ABCs, antibiotics
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Tumor: 70% with headache, classically worse in
the morning, positional, nausea and vomiting
Pseudotumor cerebri: headache worse with
awakening, valsalva, cough, bending
– Signs of increased ICP: papilledema, CN VI palsy,
diploia, visual deficits, tinnitus
– Linked with OCP use, vit A, tetracycline use, thyroid
disorders
– Diagnosed with CT for hydrocephalus, LP for high
opening pressure
– Treatment diuretics, repeat LP, CSF shunt or optic
nerve sheath fenestration
Opthalmic
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Glaucoma
– Acute angle closure: obstruction of aqueous
humor outflow leading to increased intraocular
pressure and possible blindness
– Sudden onset painful vision loss associated
with headache, nausea, vomiting, somnolence
– Exam with decreased vision, conjunctival
injection, hazy cornea, fixed/mid-position or
dilated unreactive pupil
– Needs emergent opthomology referral, eye gtts
Opthalmic
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Iritis: inflamation of the Iris
– Risk if sarcoid, STDs, collagen vascular dz
– Blurred vision, deep eye pain, photophobia, red
eye
– Exam with conjunctival injection, cell and flare
– Optho referral, topical steroids, cycloplegic
drops
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Optic Neuritis: painful vision loss due to
inflammation of optic nerve
– Consult with opthomology regarding iv steroids
Drug Related Headache
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Nitrates: symptomatic hypotension,
hypoperfusion
MAOIs: orthostatic hypotension, but can
have hypertensive crisis when taken with
sympathomimetic amines, l-dopa,
narcotics or tyramine containing foods
(cheese)
Alcohol withdrawal: treat with
benzodiazepines
Toxic
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Carbon Monoxide Poisoning
– CO competes with O2 for Hgb binding with
250x affinity
– Suspect with confined space fire, car engine
left on, several household members sick at
same time
– Half life 320 min @ RA, 82 min @ 100 %NRB, 23
min @ 3 atm HBO
– Headache, nausea, vomiting, malaise, chest
pain, weaknes, apathy, cherry red skin,
abnormal reflexes, altered mental status
– Treat with O2, consider transfer to hyperbarric
chamber
Metabolic
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Hypoxia
Hypoglycemia
Hypercapnia
High Altitude Cerebral Edema
– Due to acute hypoxia from rapid ascent
– Higher risk if pulm dz, EtOH/drug use, dehydration
– Headache, anorexia, nausea, vomiting, weakness,
altered mental status seizure/coma/death
– Treat with immediate descent, 100%O2,
Dexamethasone +/- HBO
Preeclampsia: after 20th week of pregnancy—BP
>160/110, proteinuria, peripheral edema
– May progress to eclampsia (above + seizures)
– Definitive treatment is delivery, may use hydralazine
for HTN, magnessium sulfate for seizure
Non-CNS Infection
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Systemic– viral syndromes, bacteremia,
fever may often cause generalized
headache
– Antipyretic for fever, definitive treatment for
source of infection
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Sinusitis– inflammation of ethmoid,
frontal, sphenoid or maxillary sinus
– Fever, malaise, anosmia, headache and
toothache, purulent discharge, postnasal drip,
sore throat, facial pain/pressure
– Antibiotics and nasal decongestants,
antipyretics for fever and analgesia
Non-CNS Infections
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Dental Infections—Caries and/or periapical
abscess
– Toothache, jaw pain, earache, jaw pain, tooth tender
to percussion
– Treatment involves covering exposed tooth,
analgesia, abscess drainage if appropriate
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Ear Infections
– Otitis Media– middle ear infection with ear
pain/fullness, decreased hearing, vertigo, fever.
Treat with antibiotics, antipyretics
– Otitis Externa– External Ear infection with itching,
decreased hearing, fever, tender external ear.
Treated with antibiotic drops. Caution if diabetic for
malignant OE
Post Lumbar Puncture
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Headache is secondary to loss of CSF
– Persistent headache due to CSF leak after LP
– Definitive Treatment is Blood Patch
– Keep patient supine +/- Trendellenberg
Cases
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56 yo W with throbbing right
sided headache, “darkened”
vision on the right
Cases
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21yo W with throbbing left
sided headache for 1 day
preceded by seeing bright
lights
Cases
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45yo HIV+ M c/o several day
h/o headache, blurred vision,
vertigo, nausea and vomiting
Cases
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65yo M w/ CAD and HTN with
acute onset of dysarthria, right
sided weakness
Cases
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22yo M w/ fever, stiff neck and
Questions?