Transcript File
SDMH EMC 2015
Key assessment features to ascertain in acute headache –
differential causes
When to consider neuroimaging
Become familiar with subarachnoid haemorrhage (SAH) workup
Understand the features of infective headaches
Features that may suggest uncommon but important diagnoses
HISTORY
EXAM
Acuity of onset
ABCD – primarily GCS
Prodromal features – fever, ‘flu’,
nausea, visual problems
BP and T
Syncope, meningism, eye pain,
focal neurology, facial pain,
seizures
Neck rigidity/photophobia
Detailed neurological exam
Facial sinuses
Eyes
Headache pattern
Family history – Migraine, SAH
Medications –
immunosuppressant's, recent
antibiotics
Temporal artery tenderness
Pathology – largely unhelpful.
Serum Na, BSL and ESR/CRP may assist with some
differentials
Imaging – CT head test of choice if indicated
Invasive – Lumbar puncture if SAH, meningitis, encephalitis
or Idiopathic intracranial hypertension considered
HISTORICAL
EXAM
Classic – unilateral, throbbing,
nauseating.
Common – generalized
headache, deteriorating with time
Headache preceded by aura
and/or nausea
Family history. Onset in
adolescence or young adulthood
Stereotypical – patient can
recognise it.
Migraine sufferers can also suffer
other neuropathology eg SAH
1st line - NSAID – PO/PR and Paracetamol
2nd line –
Metoclopromide 10mg IM/IV OR
Prochlorperazine 12.5mg IM/IV OR
Droperidol
1-5 IM/IV
3rd line – Chlorpromazine 12.5 mg IV in IV fluids.
Repeat x 1 if ineffective
Rehydrate – fluids often helpful
If failing to settle, consider alternate diagnosis, senior input
Triptans – expensive, frequently ineffective in ED population
Ergotamine unavailable
44 yr old female
Smoker
Sudden onset severe R sided headache whilst sitting
reading a book 3 hrs earlier
Associated nausea, vomited x 2
Otherwise well
BUT….
4 x sisters with ‘bleeds into brain’ – 2 deceased from
aneurysms in NZ
80% due to aneurysm
Median age 50
Smoking 4-5 x risk
Typically ‘worst ever’ headache
Reaching maximal severity immediately
Nausea/vomiting/syncope/seizure raise
suspicion
May only have headache
Headache may dissipate within hoursdays
Causes 12-25% of thunderclap headaches
Exam – often normal
Photophobia/nuchal rigidity
Decreasing level of
consciousness , worse
outcome
Thus need to avoid missing
the ‘sentinel bleed’
Re-bleed - 1 day to 1 month
later
CT head
First line test – non contrast
CT head
Positive result on CT CT
angiography
Will help to determine
neurosurgical plan
CT sensitivity traditionally quoted as
~ 90% at 4-12hrs after headache,
falling with time
CSF testing for RBC breakdown
(xanthochromia) - gold standard
‘Standard practice’ – if CT negative
do LP 12 hrs from onset headache
Perry et al 2011 – 100% CT sensitivity
< 6hrs headache no LP needed if
presenting under 6 hrs
LP may find alternate pathology
Definitive treatment - interventional
neuroradiology or neurosurgeon –
transfer
Analgesia
Antiemetic
Avoid hypertension and hypotension
(?140>BP>100)
?Seizure prophylaxis
Nimodipine PO within 96 hrs
Headache +fever +meningism
Frequently following URTI
May deteriorate quickly, or have
persistent headache for days
Altered LoC significant feature –
drowsiness
Vomiting common.
Seizure 25% patients
Rash in meningococcemia; may not be
present in isolated meningitis
Meningitis considered likely THEN
Dexamethasone 10mg IV then
Ceftriaxone 2g IV AND
Penicillin 2.4g IV IF
immunocompromised, age >50,
alcoholic, pregnant or debilitated
Steroid BEFORE antibiotics.
Avoid antibiotic delay
10% all-comer mortality (20%
pneumococcus)
25% neurological morbidity
Theoretical concerns about cerebral
herniation
Considered contraindicated in high
ICP (e.g. low GCS)
If signs ICP CT head
Ideally LP within 2 hrs of antibiotic
administration
PCR still possible after this
CT SIGNS OF HIGH ICP
Ventricle size
Slit-like or none
Basilar cistern size
Mildly effaced or effaced
Sulci size
Effaced or none visible
Transfalcine herniation
(midline shift)
Loss of gray-white matter
differentiation
Typical meningitis symptoms
May have viral syndrome OR
thunderclap onset
NO altered LoC, seizures or focal
neurology
Often appear ‘well’ (but miserable!)
Stable symptom course
85% enterovirus
Treatment supportive
LP confirms diagnosis
Viral infection of brain parenchyma
Headache and fever common, but not
reliably present.
Meningism mild or absent
Focal neurology signs – higher functions
Due to grey matter inflammation – aphasia, behavior
change, lethargy, movement disorder, ‘psychiatric’
phenomenon, memory loss
Seizures/confusion
Varying viral aetiologies
HSV potentially most damaging – 20%
mortality 25-40% neurological morbidity
Diagnosis made by CSF PCR
CTB required before LP
MRI/EEG supportive
LP findings similar to viral meningitis
Treatment: institute early –
Aciclovir 10mg/kg IV tds
Vasculitis of medium-large arteries
Classic symptoms of headache and
temporal artery tenderness. Jaw
claudication common.
May only have weakness, lethargy,
headaches , +/- fever +/- anaemia
Strongly associated with PMR
Occurs age >50
Only useful investigation ESR > 50
Need to prevent visual loss
If suspected – treat
Prednisone 50mg daily AND
Aspirin 100mg daily
Refer for biopsy and rheumatology f/u
Fear of brain tumour far outweighs
actual brain tumours in ED
presentations
Classic early morning headaches,
with positional change not common
Non-specific headache 70% pts
Often few other findings
Suspect with hx of
Vomiting
Neurological changes (often subtle)
Personality changes
New onset seizure (esp. focal)
Background hx Ca.
Pseudotumor cerebri, Benign intracranial hypertension
Uncommon –younger, overweight, women age 15-50
Persistent headaches, consistent with high ICP
Due to abnormal CSF production/excretion
Papilloedema characteristic feature
Risk of visual field loss
Diagnosed by LP CSF pressure >25 cm
LP therapeutic !
Treat with acetazolamide 250mg bd
Refer for follow up Opthalmology/Neurology review
Take a good headache history ; ensure to check eyes,
temporal arteries on exam
Not everyone needs a scan (but many will get one!) and
bloods not usually helpful
Migraine stereotypical; don’t diagnose 1st ever migraine if
age>30
CT +/- LP for sudden onset headaches
Don’t delay antimicrobials if meningitis/encephalitis
considered likely
Temporal arteritis only occurs age > 50
LP both diagnostic and therapeutic if IIH considered