Transcript Imaging in headaches

Imaging in
headaches
PHILIP CHUI
SAAHIR KHAN
Epidemiology
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Large study of over 3000 scans showed the following:
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0.8% brain tumors
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0.2% AV malformations
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0.3% hydrocephalus
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0.1% aneurysm
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0.2% subdural hematomas
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1.2% CVA including chronic ischemic processes
Choosing wisely campaign -> routine headaches do not need
imaging
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Incidental findings
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Costs, CT w/o contrast is $340 average, with contrast is $840.
Evans RW. Diagnostic testing for migraine and other primary headaches. 2009. Neurology Clinics: 27(2); 393-415.
History and physical
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AAN Diagnostic instrument
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How often do you get severe headaches (ie, without treatment it is
difficult to function)?
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●How often do you get other (milder) headaches?
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●How often do you take headache relievers or pain pills?
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●Has there been any recent change in your headaches?
Physical exam
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Level of consciousness
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Cranial nerve testing (esp II, III, IV, VI)
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Motor
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Reflexes
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Meningeal signs
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Coordination and gait
Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American
Academy of Neurology. Neurology 2000;55:754–762.
Warning signs
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First headache with no prior history
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CNS infection
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Intracranial hemmorhage
Sudden onset reaching intensity in seconds or minutes
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SAH
Worsening headache pattern
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Mass lesion
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Subdural hematoma
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Medication overuse
Focal neuro deficit
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Mass lesion
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Collagen vascular disease
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AV malformation
Lipton RB, Bigal ME, Steiner, TJ et al. Classificationof primary headaches. Neurology. 2004;63(3):427-435.
Warning signs
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Any change in mental status/personality
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Fever or systemic symptoms
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Headache with strenuous exercise (esp w/ trauma)
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Headache spreading into lower neck/shoulders
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New headache in an elderly person
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At risk populations
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Cancer -> metastasis
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Lyme -> meningoencephalitis
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HIV -> opportunistic infection/tumor
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Pregnancy
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Cortical vein, venous sinus thrombosis
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Carotid dissection
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Pituitary apoplexy
Lipton RB, Bigal ME, Steiner, TJ et al. Classificationof primary headaches. Neurology. 2004;63(3):427-435.
Subacute Headache
(gradual onset)
Acute Headache
(sudden onset)
Temporal Arteritis
Age > 60, ESR > 55,
temporal tenderness
Sinusitis or
Mastoiditis
“Worst in Life”
Unilateral with
Dissection or
Horner’s Signs
Chronic Headache
(>4 weeks)
Immunocompromised
Pregnancy
Typical Migraine
unilateral pulsating with n/v
and photo/phonophobia
Meningitis/Encephalitis
Atypical Pattern,
New Features, or
Neurologic Signs
fever, AMS, or meningeal signs
*
CTA or MRA
Head and Neck
CT Head
without
contrast
MRI Head
without contrast
•diffusion-weighted
MRI Head
with/without
contrast
No imaging
required
Jordan JE et al, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® headache. [online publication]. Reston (VA): American College of Radiology (ACR); 2009.
Neff, MJ. Evidence-Based Guidelines for Neuroimaging in Patients with Nonacute Headache. Am Fam Physician. 2005 Mar 15;71(6):1219-1222.
Case
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A 36 year old female presented to the ED complaining of a sudden,
acute onset, vertex headache that radiated into her neck. Symptoms
started three hours prior to arrival and she endorsed N/V. The patient
had had a similar headache five days prior that resolved with excedrin.
The patient had a past history of migraines with aura (scintillating lights
followed by nausea and right temporal throbbing headache. The
present headache was different in intensity, onset, and location. There
was no past medical history. Medications included naprosyn prn for
headaches, and birth control pills. The patient neither smoked nor
consumed alcohol.
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The physical examination as documented on the chart included BP
118/70, RR 16, HR 72, T 97. The patient was alert, cooperative, but
appear uncomfortable holding the top of her head. Pupil exam was
not documented, cranial nerves were “intact”, gait was “normal”.
A case of sudden, severe headache. Foundation for Education and Research in Neurological Emergencies. Adapted from Ferne.org,.Visited 3/11/15.
Questions
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1. A 25-year-old male with no past medical history presents to your internal medicine
clinic for recurrent headaches over the past 6 months. These headaches are
described as throbbing, 7/10 in intensity, occurring on the left side of the head, and
associated with nausea. He denies fevers, vision changes, loss of consciousness, and
weakness or numbness in his extremities. He has had to miss work three times in the
past month as a result of these headaches. When he feels the headache coming
on, he lies down in a dark quiet room until the headache passes. He has no family
history of early stroke, aneurysm, or neurological disorders. He does not drink coffee
or alcohol and cannot identify any triggers for his headaches. He has tried
acetaminophen, aspirin, and ibuprofen without adequate relief of his symptoms. His
physical examination is unremarkable, including no neurological deficits. What is the
most appropriate next step?
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CT Head without contrast
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Check ESR
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Prescribe oxycodone as needed for headache
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Prescribe sumatriptan as needed for headache
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Prescribe topiramate daily
Questions
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Correct Answer: D
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Explanation:
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This patient presents with a typical migraine without aura. Imaging (A) is
not appropriate, as the patient has no risk factors or warning signs for
life-threatening causes of headache and a normal neurological exam.
Checking inflammatory markers (B) would be appropriate in the setting
of concern for temporal arteritis, but this diagnosis is highly unlikely given
this patient’s age. Opiates (C) are not a first-line therapy for migraines.
Topiramate (E) would be appropriate for prophylaxis if migraine
frequency were greater than twice per week. Sumatriptan (D) is the
best choice in this case; it would be contraindicated if the patient had
a basilar migraine, hemiplegic migraine, or prolonged aura due to
vasoconstrictive effect.
Questions
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2. A 40-year-old male presents to your internal medicine clinic for daily
headaches over the past two weeks. The headaches are sharp, 6/10,
focused around either eye, and associated with a runny nose. His
headache today resolved in the waiting room. He states that he had
similar symptoms last year around the same time, which he attributed to
seasonal allergies, but he has been taking loratadine without adequate
relief of his symptoms. He denies fever, vision changes, weakness, and
sensory loss. His medications are loratadine as above and lisinopril for
hypertension. His physical examination is unremarkable, including no
neurological deficits. What is the most appropriate next step?
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CT Head without contrast
Chest X-Ray
Prescribe sumatriptan as needed for headache
Prescribe oxygen as needed for headache
Start verapamil and taper lisinopril as needed
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Questions
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Correct Answer: E
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Explanation:
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This patient presents with cluster headache. Given his daily symptoms,
pharmacological prophylaxis is indicated with verapamil (E). Since he is
not currently experiencing a headache, acute abortive therapy with
sumatriptan (C) or oxygen (D) is unnecessary. Imaging (A) is not
appropriate, as the patient has no risk factors or warning signs for lifethreatening causes of headache and a normal neurological exam.
Chest X-Ray (B) would be indicated in the setting of concern for
Horner’s syndrome caused by a Pancoast tumor, but this patient’s
presentation is more consistent with cluster headache.
Questions
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3. A 68-year-old female presents to your internal medicine clinic for
worsening headache over the past week. The headache is described as
left-sided, sharp, and associated with brief periods of dark vision in the left
eye. She denies fever, neck stiffness, and weakness or sensory loss in her
extremities. Her only medication is levothyroxine for Hashimoto’s thyroiditis.
She has no personal or family history of cardiovascular disease or diabetes.
Physical exam is notable for peripheral visual field deficits in the left eye,
tenderness in the left temporal region, cranial nerves intact bilaterally,
supple neck with no carotid bruit, and regular heart rhythm with no
murmurs. What is the most appropriate next step?
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CT Head without contrast
MRI/MRA Head and Neck with contrast
Check ESR
Start high-dose prednisone
Consult Rheumatology for temporal artery biopsy
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Questions
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Correct Answer: D
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Explanation:
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This patient presents with temporal arteritis with visual symptoms
concerning for impending blindness. While similar visual symptoms may
occur with stroke that would be seen on MRI (B) better than CT (A), this
patient’s history and physical exam are more consistent with temporal
arteritis. While elevated ESR (B) would be consistent with a diagnosis of
temporal arteritis, this patient’s clinical suspicion is high enough to justify
immediate treatment (D). Delaying treatment to pursue a biopsy (E) is
not appropriate.
Questions
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4. A 75-year-old female comes with her daughter to your urgent care clinic 3 days after
being hospitalized for a subarachnoid hemorrhage treated by neurosurgical evacuation
and clipping. Her daughter notes that the patient seemed drowsy and could not
recognize her when she picked her up for her appointment. When asked if she is having
any symptoms, the patient moans and points to her head. Her past medical history is
notable for atrial fibrillation previously on coumadin and diabetes. She has no known
drug allergies. Her vital signs on presentation to the clinic are T 38.4, HR 103, BP 100/60, RR
24, O2 sat 95% on room air. Physical exam shows a woman in moderate distress, lethargic,
oriented to person but not place or time, with photophobia, mild neck stiffness, negative
Kernig’s and Brudzinski’s signs, and no focal neurological deficits. Intravenous access is
obtained, blood cultures are collected, fluid resuscitation is initiated, and lumbar puncture
is performed which shows 150 WBC with 85% PMN, 10 RBC, glucose 45, protein 60 with
initial CSF gram stain negative and culture pending. What is the most appropriate choice
of empiric treatment?
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Vancomycin and piperacillin/tazobactam
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Vancomycin, cefepime, and ampicillin
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Vancomycin, cefepime, ampicillin, and dexamethasone
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Vancomycin, ceftriaxone, ampicillin, and dexamethasone
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No empiric therapy indicated, await results of CSF culture
Questions
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Correct Answer: B
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Explanation:
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This patient has high clinical suspicion for acute bacterial meningitis in
the setting of recent neurosurgery. Empiric antimicrobial therapy should
be initiated immediately after lumbar puncture, as a delay in therapy
(E) would increase the risk of irreversible neurological damage. The
appropriate regimen should include cefepime (B, C) to cover
Pseudomonas in the setting of recent neurosurgery and should include
ampicillin (B, C, D) to cover Listeria given the patient’s age. Although
dexamethasone (C, D) should normally be included if Pneumococcus is
suspected, dexamethasone is contraindicated in the setting of recent
neurosurgery.
Questions
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5. A 23-year-old male with no past medical history presents to your urgent care
clinic after being hit in the head by a baseball pitch while playing for his college
team. Four hours ago, he was hit on the right temple by a baseball traveling
approximately 90 miles per hour. He lost consciousness for less than 30 seconds, and
he denies any confusion or memory loss upon regaining consciousness. After
finishing his game, he began to develop a mild headache so he came to the clinic.
Currently, he notes a 6/10 throbbing headache worse on the right side associated
with nausea, drowsiness, and blurry vision. Physical examination is notable for
hematoma overlying right temple but no craniofacial deformities and right pupil
1mm larger than left pupil with horizontal nystagmus on medial gaze but otherwise
neurologically intact; the rest of his examination is normal. What is the most
appropriate next step in management?
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CT Head without contrast
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MRI Brain with contrast
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Admit to observation for serial neurological exams
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Discharge home with instructions to return if symptoms worsen
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Lumbar Puncture
Questions
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Correct Answer: A
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Explanation:
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This patient presents with epidural hematoma with lucid interval and
involvement of CN III. Since the patient has a headache with
neurological deficits in the setting of trauma, imaging is indicated, and
observation with serial exams (C) or discharge home (D) are not
appropriate. CT (A) will confirm the diagnosis; MRI (B) is not necessary.
The patient’s presentation is more consistent with epidural hematoma
than with subarachnoid hemorrhage, which could be worked up with
lumbar puncture (E); in this case, lumbar puncture could precipitate
herniation.