Download headache

An ED approach to the
evaluation of headache
Dr Alex Buttfield
Staff Specialist
Campbelltown Hospital
OVERVIEW
• An outline of the assessment of an adult patient
with headache:
– History
– Examination
– Focused investigations
• Main aim is to discern life-threatening headaches
from the overwhelming majority with benign
primary headaches (meaning tension, migraine,
cluster headaches)
• A few case studies
Epidemiology
• US data:
– Headache is a very common complaint
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~85% complain of headache at some point
~5% presentations to ED are due to headache
The vast majority do NOT have a serious cause
~1% of ED presentations with headache are due to lifethreatening problems
– Most commonly SAH, but high-risk when missed with
salvageable cases  aggressive investigation if suspected
Pathophysiology
• The brain parenchyma is INSENSITIVE TO PAIN
• The pain sensitive areas of the head include:
– The meninges
– Extracranial blood vessels
– Tissues lining the cavities within the skull
• Thus pain is often poorly localised and does
not often correlate with location of pathology
• Most of the pain associated is mediated via
the trigeminal nerve
DIFFERENTIAL DIAGNOSIS
Care of Tintinalli
History of presenting complaint
History of presenting complaint
• Pattern and onset of pain
– Sudden onset, severe headache very concerning
(especially with exertion)
• Think SAH.
• Other serious aetiologies
• Do not be reassured if the pain is improving at the time of
evaluation
– Worst ever headache  different to similar pattern
of headache in terms of duration, severity or
associated symptoms
– TRAUMA  ICH, SDH, extradural, skull fracture
HPI cont
• Location:
– As mentioned, this is not terribly helpful as pain is
poorly localised, thus should not be relied upon
for diagnosis
– However:
• Temporal pain/tenderness  temporal arteritis
• Dental pain  apical abscess
• Sinus headache  associated congestion, positional
headache, fever
• Occiputo-nuchal location thought to be suggestive of
SAH, but PPV low (~16%)
• DURATION:
– Steadily progressive, worsening headache over days is concerning for more
sinister pathology
• AGGRAVATING FACTORS:
– Supine position, worse in morning  raised ICP
– Worse on standing, improves with recumbency  CSF leak
– Headache recur in same environment, with multiple people effected  toxic
(carbon monoxide)
• Associated symptoms:
– FEVER  concomitant infection in extracranial location (e.g. lungs, paranasal
sinuses, mastoid air cells) can serve as nidus for meningitis
– Altered mental status  collaborative history  any change in mental status,
personality or fluctuation in consciousness
– SYNCOPE  especially if associated with sudden onset  SAH
– Nausea and vomiting  non-specific but can reflect raised ICP.
– Neck pain or stiffness suggestive of meningeal irritation
• Associated symptoms:
– Seizure  concerning for intracerebral pathology
– Visual disturbance:
• Zig-zag lines  visual aura with migraine
• Visual loss  glaucoma, temporal arteritis
– Jaw claudication  temporal arteritis
– Pain on jaw movement, clicking/snapping TMJ
disease
• ALLEVIATING FACTORS:
• Including analgesia taken
BACKGROUND HISTORY
• AGE  >50, first headache, high risk population
• IMMUNOSUPPRESSION:
• HIV/AIDS especially
• Immunosuppressive agents
• Chronic cardiac disease, liver disease
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HYPERTENSION
CHRONIC E.N.T. INFECTION
COAGULOPATHY (congenital or acquired)
MALIGNANCY
VENTRICULO-PERITONEAL SHUNT OR CNS DEVICE
THROMBOPHILIA
RECENT CNS SURGERY/PROCEDURE (including lumbar puncture)
POLYCYSTIC KIDNEY DISEASE
• MEDICATIONS:
– Especially anticoagulants, antiplatelets
– NSAIDs can increase bleeding risk
– Corticosteroids and other immunosuppressive
agents
– OCP
– Analgesic abuse
• FAMILY HISTORY:
– Sudden death, especially if known SAH
– Polycystic kidneys (autosomal dominant
inheritance)
– Migraines
• SOCIAL HISTORY:
– Especially illicit drug use
– Alcohol abuse
– Smoking
SPECIAL POPULATIONS
• PREGNANT WOMEN:
– Pre-eclampsia! Headache is warning symptom. Check
blood pressure and for protein on urine
– Rarely  cerebral venous sinus thrombosis both
during pregnancy and in the post-partum headache
– In immediate post-partum period, think post-dural
puncture headache (CSF leak) or other complication
of spinal/epidural
• OLDER ADULTS
• HIV/AIDS
EXAMINATION
• RED FLAGS:
– TOXIC APPEARANCE
– ABNORMAL VITAL SIGNS
– DECREASED CONSCIOUSNESS
– FOCAL NEUROLOGICAL SIGNS
– MENINGISMUS
– OPHTHALMOGICAL FINDINGS
– EVIDENCE OF TRAUMA
NEUROLOGICAL ASSESSMENT
• CRUCIAL!
• Systematic approach:
– Mental state
– Motor and sensory function
– Cranial nerve
– Reflexes
– Gait
– Cerebellar function
SYSTEMATIC APPROACH
• TO ASSESS FOR EXTRACRANIAL CAUSE OF
HEADACHE:
– Sinus percussion (frontal, maxillary)
– Temporal arteries
– Eye examination
– TMJ
– Alternative source of infection (respiratory, ENT,
GI)
LOW RISK PATIENTS
• Patients with prior headaches who meet the
following considered low risk:
– No substantial change in their typical headache
pattern
– No new concerning historical features (seizure,
trauma, fever)
– No focal neurological symptoms or abnormal
neurologic examination findings
– No high-risk comorbidity
INVESTIGATIONS
• BEDSIDE
• LABORATORY
• IMAGING
• BSL:
– Hypoglycaemia can lead to reversible cause of
altered mental state
– DKA with cerebral oedema is a possibility  but
diagnosis of exclusion
• ECG
Care of Life in the Fast Lane
LABORATORY
• Blood tests by and large do not add massively
to your history and examination
• FBC  leukocytosis is often non-contributory.
Severe anaemia can lead to tissue anoxia and
resultant headache
• Erythrocyte sedimentation rate  reasonable
NPV in temporal arteritis
CSF ANALYSIS
Care of Wikipedia.org
• What information do we gain from a lumbar
puncture?
• Should we wait for a CT first?
• Should we wait for the LP to give antibiotics?
• CSF analysis:
– Opening pressures  must be in lateral decubitus
position
– Protein
– Glucose
– Microscopy  white cells and bacteria, or red
cells
– Xanthochromia
• CT first?
– If raised ICP is suspected, a CT should be
performed first to determine if contraindications
to LP exist
• Antibiotics first:
– ABSOLUTELY!
IMAGING
• NON-CONTRAST CT BRAIN FIRST:
– Excludes critical lesions or mass effects requiring
emergent interventions (including traumatic
bleeds)
– A NEGATIVE STUDY DOES NOT EXCLUDE
SUBARACHNOID HAEMORRHAGE
– If SAH is found, it should be followed by a CT
angiogram to assess for aneurysmal disease
• MRI:
– Not part of routine ED work up
CASE STUDY ONE
• 43 year old male
• Sudden onset of severe headache, then
collapse
• Currently GCS 15 but ongoing severe
headache
Image care of medscape
Subarachnoid haemorrhage
• Life-threatening neurosurgical emergency
• Priorities of management:
– Neurosurgical consultation ASAP for ?clipping/coiling
of aneurysm or AVM repair
– Analgesia
– Avoid secondary brain injury:
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Hypoxia
Hypoglycaemia
Re-bleeding (judicious blood pressure management)
Aspiration
Raised ICP
– Delayed risk of cerebral vasospasm  nimodipine
CASE STUDY TWO
• 34 year old male, two years post acoustic
neuroma resection
• Presents with progressively worsening
headache and fever
• En-route to hospital, he becomes acutely
confused
Lumbar puncture results
• Microscopy:
– Red cells 240 x10^6/L
– White cells 7170 x 10^6/L, predominantly PMN
– Gram positive encapsulated diplococci
– Protein high, glucose low
This is what we are trying to avoid!
Bacterial meningitis
• Uncommon with advent of immunisation
• Treatment priorities:
– DO NOT DELAY ANTIBIOTICS!
• Ceftriaxone 2g bd
• Vancomycin if pneumococcus suspected
– Consider antivirals
– Steroids (prior to or just after antibiotics).
Dexamethasone 10mg q6h for 4 days.
– Fluid resuscitation
CASE STUDY THREE
• Young male, struck to head
• Initially lucid, now complaining of worsening
headache
• Rapidly deterioriating level of consciousness
• Left sided dilated and fixed pupil
Case courtesy of Dr Matt Skalski, Radiopaedia.org
Extradural haematoma
• A neurosurgical emergency
• Often associated with skull fracture, middle
meningeal artery laceration
• Needs immediate evacuation
• Temporising measures only in ED
Case courtesy of Dr Matt Skalski, Radiopaedia.org
Case courtesy of Dr Frank Gaillard, Radiopaedia.org
Case courtesy of Dr Jeremy Jones, Radiopaedia.org
Care of Radiopedia.org
CASE STUDY FOUR
• 55 year old male, previously well
• Heavy smoker
• 2-3 months of bifrontal headache, worse in
the morning and with recumbency
• Friends have noted increasing forgetfulness
and increasingly wild mood swings
Intracerebral malignancy
• Most often metastases from distant sites
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Breast
Lung
Colorectal
Melanoma
Renal cell
• Can be primary glioma
– Benign meningioma
• Treatment is often palliative
– Analgesia
– Dexamethasone
– Whole brain irradiation
• Surgery can either have curative or palliative intent
CASE STUDY FIVE
• 39 year old female, history of migraines. Four
days of progressively worsening headache and
behavioural change
– Only medication is a vaginal ring for contraception
• Examination unremarkable other than wordfinding difficulty
• Then has a generalised seizure
Empty Delta Sign – sinus thrombus creates filling defect on contrast-enhanced CT
*image courtesy of MediNuggets
CEREBRAL VENOUS SINUS THROMBOSIS
• Represents ~0.5% of “strokes”
– ~80% <50 years, 34% with acquired thrombophilia
– Risk factor assessment
– Either present with symptoms related to raised ICP or
venous ischaemia and focal brain injury
• Headache most commonly (90%)
– Isolated (without neurology or papilloedema) in 25%
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Altered consciousness
Altered vision
Nausea and vomiting
Seizures (up to 50% cases)
Venous anatomy and location of
thrombosis
MANAGEMENT
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Admit to a stroke unit
Anticoagulation
Seek and treat underlying cause
Seek/treat complications  raised ICP, seizures
Advanced interventions
– Clot-directed thrombolysis
– Thrombectomy
– Decompressive craniectomy (for refractory
intracranial hypertension)
TAKE HOME
• High risk history:
– Sudden onset, worst ever
– No similar headaches in the past
– Altered mental state or seizure
– Headache and syncope
– Immunosuppression
– Headache with exertion
– Salient background problems
• HIGH RISK EXAMINATION:
– Focal neurology
– Abnormal vital signs
– Altered consciousness
– Signs of raised ICP
– Meningism
– Evidence of trauma
• WHEN IN DOUBT, WORK IT UP