Download Headache in the ED

Headache/Vertigo
in the ED
Nicholas Cascone, PA-C
Headache in the ED

4% of all ED visits are due to headache
– 4% of these headache visits have serious or
secondary pathology

Objectives of evaluation:
– Appropriately select patients for emergency
investigation when critical secondary causes
are present
– Provide effective treatment for primary and
benign secondary headaches
Evaluation of Headache in ED

History
– Pattern – worst ever, first severe, steady
worsening, differences from prior headaches
– Onset – sudden headaches that begin during
exertion – up to 25% of such HA are SAH
– Associated symptoms – dizziness, nausea,
confusion, LOC, fever, neck pain/stiffness,
visual changes, seizure
Evaluation of Headache in ED

History (cont’d.)
– Medical history – trauma, previous lumbar
puncture, use of nitrates, MAOIs, exposure to
toxics (e.g., CO)
– Family history – migraines, SAH run in families
Evaluation of Headache in ED

Physical examination
– Temperature, blood pressure
– Palpate sinuses, temporal artery,
temporomandibular joint
– Eye exam for acute glaucoma, fundoscopy for
signs of hypertension, papilledema
– Thorough neurological exam

Labs
– CT scan, lumbar puncture if indicated
Killer Headaches

Subarachnoid hemorrhage
– More common in women
– Severe, constant occipitonuchal HA, “worst in
my life”
– Often presents suddenly, with vomiting and
alteration of consciousness
– History may indicate activities which raise
blood pressure (e.g., intercourse, defecation,
coughing)
Killer Headaches

Subarachnoid hemorrhage (cont’d)
– Dx: plain CT 93% sensitivity within 24 h of
onset
– If CT nondiagnostic, LP
 Xanthochromia on spectrophotometry nearly 100%
sensitive
 Naked-eye detection only 50% sensitive
– Tx: angiogram and surgery consult,
nimodipine, prohylactic phenytoin,
antiemetics, decrease BP if elevated
Killer Headaches

Meningitis
– Occipitonuchal headache with fever,
meningeal signs, altered consciousness
– Dx: immediate LP in pts without neurological
signs, normal LOC and no papilledema
 If LP delayed and bacterial meningitis suspected,
initiate empiric antibiotic tx
Killer Headaches

Subdural hematoma
– History of remote trauma with headache
– High risk patients:
 Anticoagulation
 Chronic alcoholics
 Elderly patients
– If plain CT nondiagnostic, contrast CT or MRI
– Tx: surgery consult
Killer Headaches

Brain tumor
– Headache may be unilateral/bilateral,
intermittent/continuous
– Classic presentation is headache with
vomiting, worse upon arising
– Reliable pt with no neuro findings and no
papilledema can follow-up as outpatient
within 24 hours
Other Headaches

Secondary headaches
–
–
–
–
–
–

Temporal arteritis
Acute glaucoma
Hypertensive headache
Sinusitis
Post-LP
Drug-related/toxic
Primary headaches
– Migraine
– Cluster
– Tension
Vertigo
Sensation of movement where none exists
 Peripheral causes vs. central causes – peripheral
causes usually benign, central causes can be
urgent

– Peripheral vertigo: sudden onset, intense,
paroxysmal, aggravated by position/movement,
associated with nausea or hearing loss/tinnitus,
horizontal nystagmus, fatiguable, CNS signs absent
– Central vertigo: any onset, ill-defined, constant,
variable association with position/movement/nausea,
not associated with hearing loss/tinnitus, vertical
nystagmus, not fatiguable, CNS signs usually present
Vertigo – causes

Peripheral causes
– BPPV, Ménière’s disease, labrynthitis,
ototoxicity, head injury

Central causes
– Cerebellar stroke, VBI, MS, migraine, epilepsy,
neoplasm

General causes
– Anemia, EtOH intoxication, hypoglycemia,
renal failure, thyroid disease
Vertigo - evaluation

History
– Description of sensation – vertigo, syncope/nearsyncope, disequilibrium
– Onset
– Associated symptoms
 Peripheral associated with nausea/vomiting, tinnitus/hearing
loss, photophobia
 Central associated with diplopia, dysarthria, visual
abnormalities
 Headache suggests migraine or space-occupying lesion
 Head trauma, medications
Vertigo - evaluation

Physical exam
– Ear: otoscopy, hearing exam, Webber/Rinne
– Eye: nystagmus, EOMs
– Heart rate, rhythm, murmurs
– Cranial nerves
– Cerebellar testing
– Proprioception/vibration
– Test patients with near-syncope for
orthostasis
Vertigo – evaluation

Dix-Hallpike position testing: pt seated
upright, head turned 45° to right, swiftly
reclined with head tilted backward
additional 45°; repeated with head turned
to left
– Warn pt that test may produce vertigo
– Positive test indicated by nystagmus; positive
side is side with lesion
– Contraindicated in patients with carotid bruits,
cervical spondylosis
Vertigo – evaluation

Labs
– Depend on suspected etiology
 Labrynthitis: CBC, blood culture
 Head injury: CT for bleeding
 Near-syncope: ECG, cardiac monitoring, CBC for
anemia
 Electrolytes, glucose, kidney function, thyroid
Vertigo – symptomatic treatment

Pharmacotherapy
– Scopolamine
– Antihistamines – diphenhydramine
(Benadryl®), meclizine (Antivert®)
– Neuroleptics – metoclopramide (Reglan®),
promethazine (Phenergan®)
– Benzodiazepines for anxiety – diazepam
(Valium®), clonazepam (Klonopin®)