Download Headache & Facial Pain

Headache & Facial
Pain
Chpt. 227
Jen Donze D.O.
Prepared by Brian Holod D.O.
11/10/05
Headache
• HA represents up to 4% ED visits
• Most ED pts. with benign
primary HA, but up to 3.8% with
serious or secondary pathology
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HA- ED Objectives
1. To appropriately select patients for
emergency investigation and
treatment of suspected critical
secondary HA causes
2. To diagnose and effectively treat
patients with generally benign and
reversible secondary HA causes
3. To provide effective treatment for
primary HA syndromes
4. To provide appropriate disposition
and follow-up for all discharged pts
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ACEP HA Categories
I.
II.
III.
IV.
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Critical 2° causes requiring
emergent classification and Tx
(SAH, meningitis, brain tumor with
↑ ICP)
Critical 2° causes not necessarily
requiring emergent Dx or Tx (brain
tumor w/o ↑ ICP)
Generally benign and reversible 2°
causes (sinusitis, HTN, post-LP)
1° HA syndromes (migraine,
tension, cluster)
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History
Pattern- 1st severe HA, worst ever,
worsening over several days
or significantly different from
prior HA’s
Onset- sudden onset especially w/
exertion (cough, defecation)
Location- unilateral, bilateral,
occipitolnuchal
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History
• Associated symptoms- syncope,
altered LOC, confusion, neck
pain/stiffness, visual Δ’s, fever,
seizure, jaw claudication
• Other- medications, trauma,
toxic exposures
• Family Hx- migraines or SAH
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Physical Examination
•
•
•
•
General appearance and vitals
Fever- infectious
HTN- ? HTN urgerncy/emergency
HEENT-sinuses, temporal
arteries, TMJ, dentition, IOP,
visual field defects, papilledema
• Neuro- gait, MS, Cranial nerves,
motor/sensory exam, reflexes
and cerebellar testing
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Subarachnoid Hemorrhage
• Annual incidence 1/10,000 year
in U.S.
• High mortality; 50% die within
6mo.
• ½ pts. w/ nml neuro exam @
presentation
• HA severe w/ sudden onset
• HA most commonly
occiptonuchal
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Subarachnoid Hemorrhage
• CT head 93%
sensitive within
24h, ↓ ~80%
after 24h
• LP mandatory if
neg CT and
suspect SAH
• Xanthochromia
gold standard Dx
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Hunt and Hess Classification of Subarachnoid
Hemorrhage
Grade I Asymptomatic of minimal headache and slight
nuchal rigidity.
Grade II Moderate to severe headache, nuchal rigidity,
no neurologica deficit other than
cranial nerve palsy.
Grade III Drowsiness, confusion, or mild focal deficit.
Grade IV Stupor, moderate to severe hemiparesis,
possible early decerebrate ridigity and
vegetative disturbance.
Grade V Deep coma, decerebrate ridigity, moribund
appearance.
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Subarachnoid Hemorrhage
•
•
•
•
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Neurosurgical consultation
Nimodipine 60mg PO q6h
Prophylactic Phenytoin loading
Antiemetics
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Meningitis
• Usually w/ fever & meningismus
• HA may be severe w/ rapid
onset
• Opportunistic infxn
(cryptococcal) in
immunocompromised may have
more insidious onset
• LP mandatory if any suspicion
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Intraparenchymal Hemorrhage
& Cerebral Ischemia
• 55% pts w/ intraparenchymal
hemorrhage have HA @ onset
symptoms
• 17% ischemic stroke w/ HA
• 6% TIA w/ HA
• Other neurologic signs and
symptoms will be present in
most of these pts.
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Subdural Hematoma
• Hx remote trauma
• Be careful in high risk pts
(elderly, anticoagulants,
alcoholics)
• If suspected w/ nml noncontrast CT then consider
contrast enhanced CT or MRI
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Brain Tumor
• Up to 70% pts w/ brain tumor
have HA @ time of Dx & only 8%
have abnml findings neuro exam
• May be unilateral or bilateral,
intermittent or continuous
• Classically worse in A.M. & assoc
w/ nausea & vomiting
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Temporal Arteritis
•
•
•
•
•
Almost exclusively in pts >50 y/o
Incidence 15-30/100,000 >50 y/o
More common in women
HA 60-90% pts
Severe, throbbing HA in
frontotemporal region
• Assoc. w/ jaw claudication,
PMR, vision loss 2°optic neuritis
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Temporal Arteritis
• Dx- age >50, new-onset localized HA,
temporal artery tenderness, ESR >50,
abnml temporal artery biopsy
• Tx- Prednisone 40-60mg PO QD when
suspected, urgent referral for
definitive Dx and follow-up
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Opthalmic Disorders
• Glaucoma, optic neuritis, iritis
may present w/ HA
• Usually can be distinguished by
careful Hx, eye exam & IOP
measurement when indicated
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Hypertension
• Higher diastolic pressures assoc
w/ more severe HA’s
• HTN may be sign of other cause
HA (stroke, preeclampsia,
pheochromocytoma) or 2° pain
& anxiety from primary HA
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Sinusitis
• Assoc w/ facial pain & HA
depending on sinuses involved
• HA can vary w/ head position
• Purulent nasal discharge,
maxillary toothache, abnml
transillumination, poor response
decongestants
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Drug, Toxins & Metabolic HA
• Nitrates, MAOI’s, chronic
analgesic use
• MSG or CO
• Hypoxia, hypercapnia &
hypoglycemia
• EtOH withdrawl
• Dx w/ Hx and appropriate tests
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Pseudotumor Cerebri
• Young, obese pts w/ long standing HA
• N/V and visual Δ’s may be present
• Linked to OCP, Vit A, thyroid
disorders and tetracycline
• Papilledema, nml LOC, nml CT &
marked ↑ CSF pressure on LP
• Tx-acetazolamide and steroids,
repeat LP’s or shunt if meds fail
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Internal Carotid/Vertebral
Artery Dissection
• Rare, but frequently assoc w/HA
• Spontaneous or 2° trauma
• Most eventually develop neuro
symptoms
• Dx usually by angiography,
duplex scan or MRI
• SAH may be caused by dissection
& must be R/O prior
anticoagulation
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Post LP HA
• 10-36% pts who undergo LP have
HA within 24-48h
• D/T persistent CSF leak from
dura
• Minimize w/ small bore or
noncutting needles
• Tx w/ analgesics, IVF, IV
caffeine or blood patch
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Primary HA Syndromes
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Migraine
• Common, onset early teens
• Prevalance 5% male, 16% female
• Primary response of brain tissue
to a trigger resulting in
dysfunction of pathways that
modulate sensory input w/ 2°
disorder of vasculature
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Migraine
• Most w/o aura
• Slow onset, lasts 4-72h
• Typically unilateral and
pulsating, worse w/ physical
activity
• N/V, photo/phonophobia
frequently present
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Migraine
• Visual aura most common
• Other auras include aphasia,
hemipariesis, hemiparesthesia,
other speech difficulties or
brainstem symptoms
• Migraine prodromes-lethargy,
hyperactivity, yawning,
depression, food craving,
polyuria or fluid retention
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Migraine-TX
• DHE- 5HT1B/1D agonist w/ antiemetic
1st line
• Triptans- more selective 5HT1D
agonists cause less N/V
• Metoclopramide, chlorpromazine,
prochlorperazine, ketorolac and
droperidol have been effective in
RCT’s
• Place in dark, quiet room and
rehydrate pt.
• Opioids less effective than other
agents
• Dexamethazone effective reducing
rate recurrent migraine after std Tx
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Migraine
• Migraines generally improve w/
pregnancy, try
nonpharmacologic therapy (rest,
ice) first then consider
acetaminophen or
metoclopramide
• Preventive therapy by avoiding
triggers and pharmacologically
in collaboration w/PCP or neuro
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Tension HA
• Thought 2° extracranial muscle
tension, although unproven
• May share common pathway w/
migraine
• Bilateral, non-pulsating, not
worse w/ exertion & no N/V
• Tx w/ simple analgesics or
NSAIDS
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Cluster HA
• Rare, prev 0.4% population
• Short lived w/o Tx
• More common in men, usually
after 20 y/o
• Dysfuction trigeminal nerve
suspected
• Response to 5HT agonists
suggests common mechanism w/
migraines
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Cluster HA
• Severe unilateral orbital,
supraorbital or temporal pain
• Pts. Can rarely lie still
• Associated w/ conjuctival injection,
lacrimation, nasal congestion,
rhinorrhea, facial swelling, miosis or
ptosis
• Occur in clusters over weeks and may
then remit for years
• High flow O2, DHE & sumitriptan
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Temporomandibular
Disorder
• Dysfuction TMJ, surrounding
muscles or ligaments
• TMJ noise and pain w/
movement, limited jaw
movement, jaw locking, bruxism
and tongue, lip or cheek biting
• Multidisiplinary approach
• Radiographs little help
• NSAIDs initial Tx
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Trigeminal Neuralgia
• Severe unilateral pain in
trigeminal nerve distribution
lasting seconds
• Nml neuro exam
• No pain between paroxysms
• Carbamazepine effective Tx, Dx
unlikely if Tx fails
• Intractable symptoms despite
medical Tx refer neurosurgeon
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Questions
1. All are causes of primary HA
syndromes except?
a)
b)
c)
d)
Migraine
Brain Tumor
Tension
Cluster
Answer: b
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Questions
2. A normal non-contrast CT
excludes the possibility of SAH?
True/False
False- Up to 12% pts may have SAH
& nml CT exam
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Questions
3. All are characteristics of HA
with potentially severe
underlying pathology except?
a)
b)
c)
d)
Sudden onset
Papilledema
Relief with Tylenol
Change in Mental Status
Answer: C
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Questions
4. In a patient with suspected
temporal arteritis, the most
appropriate ED management would
be?
a) Refer for temporal artery biopsy as
outpatient
b) Discharge with narcotic medication for
pain
c) Rest in dark room and take OTC
analgesics
d) Immediate Prednisone therapy
Answer: D
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Questions
5. Benign, reversible secondary
HA syndromes include all of
the following except?
a)
b)
c)
d)
Meningitis
Sinusitis
Post-LP HA
Chronic analgesic use HA
Answer: A
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