Evaluation Of The Emergency Department Patient With A Headache

Evaluation Of The Emergency Department Patient With A Headache SAUSHEC EM Faculty Introduction and Epidemiology 90% of persons in the U.S. have a headache each year 50% will seek medical attention 2% of all ED visits are for the chief complaint of headache Classification Primary • Those without an underlying abnormality • Migraines, cluster, tension Secondary • Those headaches that are part of a symptom complex associated with some underlying abnormality • Hundreds • About a dozen dangerous Primary Headaches Cluster headaches • Parosxysms of intense pain lasting minutes that occur repeatedly over 30 minutes to 3 hours • Unilateral, and often retro-orbital • Males > females, age of onset 20’s to 30’s • Lacrimation and rhinorrhea • Partial Horner’s syndrome Primary Headaches Migraines and tension headaches • Considerable overlap of symptoms • Food triggering a headache is highly suggestive of a migraine • Some times it is easy to distinguish the two types of headaches • No real need to distinguish the two in the ED Secondary Headaches Life and eyesight threatening causes of headaches fall in this category History and physical very helpful Ancillary testing to “rule out” these diagnoses Dangerous Diagnoses Subarachnoid Hemorrhage Mass Meningitis and/or encephalitis CVA CO poisoning Temporal Arteritis Dangerous Diagnoses Glaucoma Hydrocephalus Cavernous Sinus Thrombosis Epidural and/or Subdural hematoma Pre-eclampsia Hypertenive Emergency Key Questions in the History Why did you come to the ED for this HA • First or worst • Worrisome associated symptoms • Last straw Last straw less worrisome Key Questions in the History Have you had similar HA’s in the past? • “no” = “first or worst” • “yes” should prompt “what is different?” • The key to discovering the cause of this HA could be in the answer Key Questions in the History How did the HA start? • Sudden vs. gradual • What were they doing Key Questions in the History Where does your head hurt? • Can be helpful in focal process  Temporal => temporal arteritis  Retro-orbital => glaucoma, cluster  Hemicranial => migraine  Band-like => tension • SAH, meningitis, CO, HTN, most often global Key Questions in the History What is the character of the pain? • Ache more common with  SAH  Mass • Pulsatile  Migraine  Temporal arteritis Key Questions in the History Do you have any other medical problems? • Consider complications of co-existing medical problems or their treatment • HIV • Cancer • Pregnancy Key Questions in the History What other symptoms do you have? • Develop before, during or after onset of HA • Fever • Neuro deficits • Visual disturbances • Jaw claudication Diagnostic Alarms in the History and Physical Alarm Differential Workup HA’s begin after the age of 50 Temporal arteritis, mass CT, ESR Diagnostic Alarms in the History and Physical Alarm Differential Workup Sudden onset of HA SAH, bleed into mass CT, LP Diagnostic Alarms in the History and Physical Alarm Differential Workup HA increasing in frequency and severity Mass, subdural, medications, toxins CT, metabolic screen Diagnostic Alarms in the History and Physical Alarm Differential Workup New onset HA in Meningitis, patient with HIV or abscess, metastasis CA CT, LP Diagnostic Alarms in the History and Physical Alarm Differential Workup HA with systemic illness Meningitis, encephalitis, lyme disease, collagen vascular disease CT, LP, serology Diagnostic Alarms in the History and Physical Alarm Differential Workup Focal neurologic deficits CVA, mass, subdural, AVM, lupus CT, labs Diagnostic Alarms in the History and Physical Alarm Differential Workup Papilledema Mass, pseudotumor, meningitis CT, LP Diagnostic Alarms in the History and Physical Alarm Differential Workup HA following trauma Subdural, epidural, post concussive CT Diagnostic Alarms in the History and Physical Alarm Differential Workup Pregnancy Pre-eclampsia UA, HCG, blood pressure Physical Exam Vital signs Cranium Cardiovascular system Neurologic Dangerous Headaches Subarachnoid Hemorrhage • • • • Traumatic vs. non-traumatic Rupture of aneurysm or AVM Sudden onset, maximal within 1 minute 50% will have some change in mental status • Pain usually global, radiating to neck, back, arms Dangerous Headaches Subarachnoid hemorrhage • Associated symptoms occasionally • ½ will have had or are having a sentinel bleed • CT will detect 90-98% of SAH • LP must be done Dangerous Headaches Mass lesion • • • • Invade or stretch pain sensitive structures Usually gradual onset, recurring Pain at sight of tumor but highly variable Worse after being recumbent Dangerous Headaches Meningitis/encephalitis • • • • Fever, HA, stiff neck = LP Global headache N/V occasionally Movement of eyes causes pain Dangerous Headaches Carbon Monoxide Poisoning • • • • • Headache and flu-like symptoms Fall/winter Family members with similar symptoms Better upon leaving house Send venous or arterial blood for carboxyhemoglobin levels by co-oximetry Dangerous Headaches Temporal Arteritis • • • • • Age > 50 Ipsilateral ocular complaints occasionally Localized tenderness Systemic symptoms Usually temporal but can be generalized Dangerous Headaches Glaucoma • Pain in and around eye + decreased vision = glaucoma until proven otherwise • May complain only of HA, N/V • Red eye, cloudy cornea, decreased vision, fixed mid-point pupil Dangerous Headaches Hydrocephalus • Adult or child with VP shunt and headache should prompt search for shunt malfunction • Usually mental status changes • Shunt series and CT Dangerous Headaches Cavernous Sinus Thrombosis • Rare but deadly • Thrombus typically initiated by spread of infection • Acutely ill • 95% will have some major PE finding • CT 80% sensitive, MR/CT with contrast gold standard • Mortality 20% to 78% Dangerous Headaches Subdural/epidural • Epidurals  Arterial  Form and present quickly • Subdurals  Bridging veins  Can form slowly  Atrophy predisposes Dangerous Headaches Pre-eclampsia • HA may be presenting complaint • Edema of hands and face, proteinuria, HTN • Presence of HA classifies them as severe • Check UA, HCG Dangerous Headaches Hypertensive emergency • End-organ damage  CNS  Heart  Kidneys • Typically will have a diastolic > 130 mmHg Dangerous Headaches Acute Stroke • 50% will have an associated HA • Location and pattern highly variable • Associated stroke symptoms, i.e. hemiplegia, dysarthria Summary Headaches are common Most are from benign cause At least a dozen life or eyesight threatening causes of headache “rule out” these diagnoses in the ED H&P main tool CT, LP the rest