philip bossart, md 1 headache treatment: what’s the latest?
TRANSCRIPT
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Philip Bossart, MD1
Headache Treatment: Headache Treatment: What’s the Latest? What’s the Latest?
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Philip Bossart, MD2
Philip Bossart, MD
ProfessorDivision of Emergency Medicine
University of Utah College of MedicineSalt Lake City, Utah
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Philip Bossart, MD3
Session ObjectivesSession Objectives
• How to Diagnose Life Threatening Causes of Headache
• How to Diagnose Migraine Headaches
• How to Treat Migraine Headaches in the ED
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CartoonCartoon
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Philip Bossart, MD5
Clinical CaseClinical Case• 20 year old female has a chief complaint
of headache. HA started 6 hours ago. Similar but milder HAs in the past. Prior headaches resolved with ibuprofen and rest but not today’s. Pain is bilateral, 10/10 intensity, with photophobia and phonophobia. She noted blurry vision before headache. Denies nausea, fever, focal weakness or numbness. She is late for her period.
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Philip Bossart, MD6
Case Presentation (cont’d)Case Presentation (cont’d)
• Her exam shows a BP of 120/80, HR of 70, RR of 20 and she is afebrile. She is alert and Ox3 but is in significant distress from pain. Scalp is tender, pupils 2 mm and reactive. Heart, Lung, and Abdominal exam are normal. GCS is 15. Cranial nerves and motor, sensory cerebellar and DTR testing is all normal.
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Philip Bossart, MD7
Case Presentation (cont’d)Case Presentation (cont’d)
• What tests need to be performed if any?
• What is the most likely diagnosis?
• How should she be treated?
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Philip Bossart, MD8
Key Clinical QuestionsKey Clinical Questions
• What are the life threatening causes of acute headache?
• What are the “red flags” which suggest a serious secondary HA?
• What are the IHS criterea for migraine?
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Philip Bossart, MD9
Key Clinical Questions Key Clinical Questions (cont’d)(cont’d)
• How should migraines be treated in the ER?
• What are the contraindications to Triptans and DHE?
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Philip Bossart, MD10
Life Threatening Causes of HeadacheLife Threatening Causes of Headache
• Intracranial bleed (esp. SAH)
• Meningitis
• Carotid or vertebral dissection
• Sinsus thrombosis
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Philip Bossart, MD11
Other Serious Secondary HAsOther Serious Secondary HAs
• Mass lesions, intracranial hypertension, temporal arteritis, hypertensive encephalopathy, hypoxia, hypercapnea, CO toxicity, glaucoma
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Philip Bossart, MD12
What are the “red flags” which What are the “red flags” which suggest a serious headache?suggest a serious headache?
• Thunderclap headache: SAH, vascular dissection, venous thrombosis, pituitary apoplexy.
• Headache onset during exertion: SAH or dissection
• HIV and Immunosuppression: infections and tumors
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Philip Bossart, MD13
““Red Flags” (cont’d)Red Flags” (cont’d)• New onset headache over age 50: mass
lesions and temporal arteritis
• Any neurologic sign or symptom: This is the best predictor of intracranial pathology. Look for papilledema, Horner’s syndrome, glaucoma. (Exception is typical migraine aura.)
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Philip Bossart, MD14
““RED FLAG” MnemonicRED FLAG” Mnemonic“S N O O P S”
SSYSTEMIC SYMPTOMS (e.g. fever,weight loss)
NNEUROLOGIC SYMPTOMS/SIGNS
OONSET (SUDDEN)
OOLD AGE (50 YEARS)
PPRIOR HISTORY (New Headache)
SSECONDARY ILLNESSES (AIDS, CANCER)
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Philip Bossart, MD15
What are the IHS criterea for What are the IHS criterea for diagnosing migraines?diagnosing migraines?
• At least 5 episodes• 4 to 72 hour duration• At least 2: unilateral location;
pulsating; moderate to severe; aggravated by activity
• At least 1: nausea and/or vomiting; photophobia and phonophobia
• History and Exam do not suggest another diagnosis
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Philip Bossart, MD16
How should migraines be How should migraines be treated in the ER?treated in the ER?
• Migraine specific medications (triptans, DHE, phenothiazines) are preferred
• Parental route if severe, long standing, or vomiting.
• Many medication choices without good data on best one to use
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Philip Bossart, MD17
Migraine Treatment (cont’d)Migraine Treatment (cont’d)
• Phenothiazine
• Triptan or DHE
• Ketorolac
• Valproic Acid
• Narcotics
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Philip Bossart, MD18
Migraine Treatment (cont’d)Migraine Treatment (cont’d)
• Prochlorperazine 10mg IV or Metachlopramide 10mg IV, Followed by: DHE 1mg IV if nec.
• Sumatriptan 6mg SQ followed by phenothiazine if nec.
• Some add diphenhydramine 25mg IV to phenothiazine to prevent akasthesia
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Philip Bossart, MD19
Migraine Treatment (cont’d)Migraine Treatment (cont’d)• Ketorolac 30mg IV or IM• Chlorpromazine .1mg/kg IV (diluted
in 20 cc saline) watch for hypotention
• Valproic acid 500mg to 1000mg IV• Intranasal Lidocaine• Narcotics
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Philip Bossart, MD20
What are the contraindications What are the contraindications to Triptans and DHE?to Triptans and DHE?
• Widely used medications with excellent safety profile
• Chest pain is common but not serious and is not necessarily ischemia
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Philip Bossart, MD21
Contraindications to Contraindications to Triptans and DHE (cont’d)Triptans and DHE (cont’d)
• Known CAD or CVD
• Uncontrolled hypertension
• Pregnancy
• Hemiplegic or basilar migraine
• Within 24 hours of prior use
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Philip Bossart, MD22
Case ConclusionCase Conclusion
• No red flags
• CT scan not indicated
• The only lab test done was a pregnancy test which was positive
• Diagnosed with “migraine with aura”
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Philip Bossart, MD23
Case Conclusion (cont’d)Case Conclusion (cont’d)
• Pregnancy reduces migraines in most patients but may get worse
• Triptan and DHE contraindicated since she is pregnant
• Treated with Prochlorperazine 10mg IV with prompt relief of HA
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Philip Bossart, MD24
Case Conclusion (cont’d)Case Conclusion (cont’d)
• Since she was pregnant and had infrequent attacks, no preventive medications were given
• Discharged home with OB folllow up.
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Philip Bossart, MD25
Questions??Questions??www.ferne.org
Philip Bossart, [email protected]
ferne_2005_aaem_france_bossart_ha_fshow.ppt 8/27/2005 2:38 AM