“My head hurts”

Aliza Moledina MS3Emergency Medicine Clerkship Rotation

PAL Session April 29th, 2015

Case

• Case: A 30 year old woman presents to the ED with a severe headache for the last 24 hours. Vitals: BP 140/90; P 85; RR 18.

• The patient is holding her head and asks for the lights to be turned out. She then proceeds to vomit on you as you approach to examine her.

Headache

• Classification– Primary headache• benign, no organic cause• usually recurrent

– Secondary headache• headache caused by underlying organic disease

Secondary Headaches

• 1) Vascular– intracranial hemorrhage including SAH– SDH, EDH– Ischemic cerebrovascular disorder (ie stroke)

• 2) Infection/Inflammatory– meningitis, encephalitis– brain abscess– sinusitis

• 3) Traumatic – concussion, SDH, EDH

Secondary Headache

• 4) Autoimmune- vasculitis including temporal arteritis• 5) Metabolic/Systemic- hypoxia/hypercapnia, CO, hypoglycemia, preeclampsia• 6) Iatrogenic- medication induced - post LP• 7) Neoplastic- brain tumour, metastasis• 8) Other– Acute angle closure glaucoma

Primary headache

• Tension • Cluster• Migraine

History

• History of Presenting Illness– OPQRST

– Onset - sudden vs gradual– Frequency, Duration, Progression– Alleviating/Precipitating Factors

– Age at onset, pattern, trigger– Similar headaches in the past?– Prodrome/aura– Associated symptoms: neck stiffness, nausea and

vomiting, photophobia/phonophobia, TMJ clicking, jaw claudication, neurological sx

History (continued)

• Review of Symptoms– constitutional– neurological symptoms– visual changes– sinus symptoms - PODS– GI: nausea/vomiting– Pregnancy

• Past Medical History:• immunosuppressed states, hx of malignancy, brain lesions/surgery, hx migraines

• Medications/Allergies: including Acetaminophen, NSAID, triptan, opiods • anticoagulants, glucocorticoids

• Family History SAH• Social History:

– illicit drugs, toxic exposure (ie CO)

Red flags on history

• Headache of sudden rapid onset• History of altered mental status• Occipitonuchal radiation of headache• First severe headache after age 35• Prior or coexistent infectious disease• Onset during exertion• Immunosuppresion• Environmental exposure

Physical Exam

• Vitals• General: note traumatic findings• Full Neurologic exam - includes LOC, orientation, pupil

symmetry, focal neurological deficits• HEENT- field of vision, fundoscopy (retinal hemorrhages,

papilledema), red eye, temporal artery tenderness, sinus palpation, TMJ, otoscopy

• Neck: meningismus • MSK - head and neck - muscles, tenderness• Kernigs/Brudzinski’s sign• ROS

Physical exam

• Kernig

• Brudzinski’s sign

Red flags on physical

• Papilledema• Altered LOC• Fever or toxic appearance• Meningismus• Focal neurological deficits• Signs of head trauma

When to order head CT/LP?

• CT head: – 1 or more high risk features on history or physical

(see red flag signs)• LP if SAH or infection are in the differential

diagnosis– LP always performed in patients with suspected

SAH in whom the CT scan is normal.

Meningitis

• inflammation of meninges• Epidemiology:– 250-700 cases in Canada per year– bimodal distribution: young children < 2 years and

elderly >50

Meningitis

• Organisms:– Streptococcus pneumoniae:– Neisseria meningitis (Meningococcus)– Hemophilus influenzae

– Other organisms:• Children: GBS, E.coli• Elderly (>50) and comorbidities: Listeria monocytogens

Meningitis

• Symptoms– pro-drome of malaise or URTI– classic triad: fever, nuchal rigidity, change in mental status– headache– photophobia– confusion/lethargy or coma– seizure– petechial rash and palpable

purpura (meningococcal meningitis)

Meningitis

• Signs– +/- cranial nerve abnormalities– meningismus – Positive Kernig’s

Meningitis

• Positive Brudzinski’s sign

Investigation

• CBC, lytes, blood C+S• CSF: Lumbar puncture most important– opening pressure, cell count + differential, glucose, protein,

Gram stain, bacterial C&S– AFB, fungal C&S, cryptococcal antigen in

immunocompromised patients, subacute illness,– suggestive travel history or TB exposure– PCR for HSV, VZV, EBV, enteroviruses if viral cause suspected

• Imaging: CT head/MRI– usually normal in meningitis

CT head before LP:

• One or more of the following risk factors– immunocompromised state– Hx of CNS disease (mass lesion, stroke, focal

infection)– New onset seizure (within one week of

presentation)– Papilledema– Abnormal LOC– Focal neurological deficit

CSF Analysis

Management of Meningitis

• ABCs to stabilize patient• Early empiric therapy: do not wait for investigations• Age 1 month - 50 years: IV (cefotaxime or

ceftriaxone) + vancomycin• elderly >50 and immunocompromised: IV

(cefotaxime or ceftriaxone), vancomycin and ampicillin (add coverage for Listeria and GNB):

• adjunctive dexamethasone in adults• control ICP

Subarachnoid Hemorrhage

• Definition: bleeding into subarachnoid space• Etiology– trauma (most common)– spontaneous • ruptured aneurysms (75-80%)• idiopathic (14-22%)• AVM (4-5%)

SAH

• Epidemiology:– 10-28 / 100 000 population/year– Peak age 55-60, 20% under age 45

• Clinical Features spontaneous SAH– sudden onset severe “thunderclap headache” usually after exertion

(“worst headache of my life”)– nausea/vomiting, photophobia– meningismus (irritation of meninges): positive Kernigs and Brudzinski’s– decreased LOC– focal deficits– ocular hemorrhage in 20-40%– reactive HTN

SAH Investigations

• non contract CT • LP - if CT negative but high suspicion. – elevated opening pressure (> 18 cm H2O)– bloody initially, xanthrochromic supernatant with

centrifugation (“yellow”) by 12 h, lasts 2 weeks• CT or MR angiogram (aneurysm gold standard)

SAH Treatment

• stabilize patient - monitor vitals, ECG for arrhythmias, analgesia

• Stop source of bleeding• ruptured aneurysm: endovascular coiling or surgical clipping

• Acute management – lower BP with IV labetalol

• Short term management– hospitalize 1-2 weeks for monitor, use supportive care– if new neurological symptoms, transcranial doppler or

cerebral angio to monitor for vasospasm

Primary Headaches

• 3 main:– tension headache– migraine headache– cluster headache (not discussed today)

Migraine

• Onset can be associated with trigger such as food, stress, sleep disturbance, hormonal changes

• 4 stages: prodrome aura headache post-drome • Aura: reversible cognitive dysfunction– gradual buildup over 5-20 minutes and lasts less than 60

minutes– visual, sensory and/or speech symptoms

• flickering lights, spots or lines, loss of vision, scintillating scotoma• sensory: parasthesia and numbness• speech: dysphasic speech disturbances

Migraine headache

• unilateral throbbing and pounding • usually localized to frontotemporal region,

may radiate to neck• usually between 4 hours - 3 days• +/- nausea/vomiting, photophobia or

phonophobia • Clinical diagnosis, diagnosis of exclusion

Migraines

• Treatment in Emergency department moderate-severe migraine– abortive therapy with Triptans (ex Sumatriptan 6 mg SC)– if N/V - then antiemetics/dopamine receptor antagonist

(ex Metoclopramide 10 mg IV or prochlorperazine 10 mg IV)• diphenhydramine 10-20 mg IV q1 hour up to 2 doses to

presevent akathisia and dystonia from metoclopramide or prochlorperazine

– Prevent early recurrence with steroid Dexamethasone 10-25 mg IV or IM

Tension Headache

• most common headache, lifetime prevalence 30-80%

• episodic or chronic• band-like or vice like pressure, usually bilaterally• pain typically mild to moderate, not severe• not aggravated by routine physical activity • no nausea/vomiting/photophobia/phonophobia• Diagnosis of exclusion

Management of tension headache

• Lifestyle modification – relieve stress

• Analgesic if episodic – NSAID, acetaminophen

• TCA (amitriptyline) - 1st line for chronic tension headache– NaSSA (mirtazapine) or SNRI (venlafaxine) is 2nd

line

Questions?

Thank you

References

• Uptodate• Medscape• Lifeinthefastlane.com• Toronto Notes 2014