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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 • • • • ~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 • • • • • • • • 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: • • • • • 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 – – – – – 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% • • • • Altered consciousness Altered vision Nausea and vomiting Seizures (up to 50% cases) Venous anatomy and location of thrombosis MANAGEMENT • • • • • 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