Headache

1. Headache • University of Utah Emergency Medicine • Medical Student Rotation

2. Objectives • Describe high risk features of headaches • Describe appropriate work-up for high risk headache • List common causes of headaches • Describe treatment for common headache syndromes.

3. Case 1 • 39 y/o male presents with severe headache • Began 4 hrs prior to presentation • Associated with nausea and photophobia • Vitals T 38.1 RR 20 BP 150/92 HR 110 • Exam / Additional history ? • Differential ?

4. High Risk features • Onset - sudden / maximal at onset (<1 min lasting > 1 hr) - 15-25% association with SAH, up to 37% associated with some serious pathology. • Exertional - 10% associated with organic pathology • Fever - associated with infections, autoimmune, SAH • Meningsmus - only 50% of pts with meningitis demonstrate on exam. • Age - over 55 with new headache 10-15% associated with organic pathology • Abnl neuro findings or mental status • HIV, SLE, Cancer, Immunocompromise • Persistent Headache > 2 months • ————

5. Evaluation • What tests do you want to order? • Why?

6. Neuroimaging • CT - non contrasted • sensitivity for SAH is time dependent and probably equipment and reader dependent • up to 97% sensitive in first 12 hrs • 90 % first 24 hrs, 50% by 1 week.

7. Neuroimaging • Contrasted CT - indications HIV, immunosuppression - useful for intracerebral fungal infections • CTA, MRI/MRA - 85-95% sensitive for cerebral aneurysm - CTA better, higher miss rate with <5mm or with vasospasm • Currently no radiologic study adequate to exclude SAH - estimates from 0-15% missed with CT only workup in first 24 hrs.

8. Lumbar Puncture • CSF shows RBC and xanthrochromia with SAH. Rapidly diffuse into CSF, though may have false negatives before 2 hrs after bleed • 20% of taps are traumatic • Constant RBC from tube 1 - 4 very concerning • Infections - increased WBC, low glucose, high protein

9. CT Scan shows SAH • Blood between pia and arachnoid • 80% from aneurysms. High mortality (50% in 6 months) and permanent deficits (33%) • 30-50% have sentinal bleed around 2 weeks prior to rupture. • Linear increase with age from 24. Average age around 50.

10. Case 2 • 43 y/o female with headache, N/V, photophobia • Preceding wavy visual loss • VS T 37.2 RR 12 HR 100 BP 150/87 • Exam / Additional History? • Workup / Treatment ?

11. Migraine • 90% of ED headaches - Migraine, Tension, Mixed benign • Spectrum - Migraine with aura (classic), Migraine without aura (common), tension • Dopamine, Serotonin, inflammatory peptides ---> Vasodilatation, peri-vascular inflammation • Women > men, usually start prior to age 30. Age over 55 at onset more predictive of organic pathology • 80% have FH of migraine. • 20% with aura, 80% without aura, 40% bilateral

12. Migraine Treatment • Dopamine antagonists • Compazine > Reglan IV 85% effective in acute attacks, less effective for >24hrs • Also Haldol, Thorazine • NSAID’s - block prostaglandin and serotonin release, inhibit platelet aggregation, first line out pt therapy • Ergotamines (DHE) - inhibit serotonin, cerebral vasoconstrictor - caution or don’t give with angina, poorly controlled hypertension, peripheral vascular disease, MAOI’s • 5HT1 agonists - cause vasoconstriction and suppress inflammation Maxalt, Imitrex, Zomig - caution or contraindicated with CAD/angina, HTN, PVD, MAOI’s. • Narcotics - not first line therapy, rescue only, may cause rebound headaches, contribute to chronic daily headaces and analgesic overuse headaches, should generally be avoided.

13. Case 3 • 72 y/o female with 5 days of temporal parietal area headache, relative acute onset. • Complains of intermittent double vision • VS T38.1 RR 12 BP 128/82 HR 84 • Exam/Additional History? • Work-up?

14. Temporal Arteritis • Chronic systemic vasculitis medium and large arteries • Over 50 years old mean 72, F>M • Visual loss worst complication - up to 33% with bilat visual loss • Generally sudden onset temporal headache, can be anywhere, visual loss can be painless. Systemic symptoms common, fever, weight loss, anorexia, mailaise, memory impairment. • Polymyalgia Rheumatica - sig overlap, sudden shoulder girdle pain • Dx. -age over 50, headache, ESR > 50, temp art tender or positive biopsy. Also consider CRP. • Treatment consists of steroid treatment if suspected and temporal artery biopsy within one week.

15. Case 4 • 21 y/o obese female with diffuse aching headache for 1-2 weeks • “Whoosing in my ears” • Occasional dimming of vision, esp after standing up lasts for a few seconds • Recent PMH - Macrobid for UTI • Exam/Workup?

16. Idiopathic Intracranial Hypertension • 8:1 Female to male, incidence increases with weight over normal • Nonspecific variable headache. • Pulsatile tinnitus • Visual - transient visual loss or dimming, bilat or unilat. May have horizontal diplopia (6th CN impairment), may have sudden visual loss from intraocular hemorrhage after chronic papilledema

17. Work-up • CT - r/o other causes • MRI with gadolinium, MRV - excludes dural venous thrombosis, malignancy, inflammatory conditions • SLE w/u esp in males and non-obese pts • Medication history - lots of meds, including Bactrim, macrobid, lithium, Accutane, tagamet, steroids, norplant, tamoxifen, tetracycline, etc

18. Work-up • Physical exam • Papilledema • Visual field deficit - esp inferior nasal quadrent • Increased optic nerve diameter • Unilateral or bilateral 6th nerve palsy (psuedo-localizing)

19. Lumbar puncture • Opening pressure - greater than 25 cm in obese pts, or 20 cm in non-obese • Best performed lateral decubitus • may require sitting position in obese pts • transition to side after successful puncture • 20 cc large volume tap is therapeutic

20. Treatment • Important to preserve visual function • Diamox (CA inhibitor) 250 mg po qid • Steroids - for emergent treatment of visual loss • VP or LP shunt. Optic nerve fenestrations (more effective in some studies) • Weight loss • Discontinue offending agents

21. Case 5 • 33 y/o Male with severe left temporal and peri-orbital pain, sharp, severe, intermittent, lasts 10-15 minutes at a time • Symptoms have been going on for 1 week, worsening • Pt screaming and holding head intermittently during evaluation • Further History/exam/WU?

22. Cluster headaches • Predominantly male (2:1) mean onset 30 years old • Episodic or chronic • Attacks are unilat, last minutes to hours, peak over 10-15 minutes (remember SAH maximal within 1 minute) associated with unilat rhinorrhea, lacrimation, conjunctival injection, Horner’s syndrome (ptosis, miosis, anhydrosis)

23. Causes • Unknown • Trigeminal nerve involved (V1,V2) • Vasodilation • Histamine • Circadian • 80% smokers, 50% heavy ETOH use (may trigger attacks during symptomatic interval)

24. Treatment • Oxygen - during initial phase of attack, questionable value • Imitrex and DHE - treatment of choice • Corticosteroids - 8-12 hrs maximal 2-3 days • Capaiscan to nostril, Lidocaine 1 cc of 10% with swab to each nostril (MAD atomizer?) • Narcotics, NSAIDS, abuse potential

25. Case 6 • 65 y/o male • Sharp pain shoots down face to nose and jaw. Triggered by shaving, touch to face. “Feels like I’m being electrocuted Doc” lasts few seconds at time. • Pt has twitching and spasm of side of face several times during history. • Normal PE except...

26. Trigeminal Neuralgia • Unclear etiology - caused by pain from trigeminal nerve, usually V2 and V3 (V1 and V2 in cluster headaches) • Older pts - 60 + (in younger patient consider secondary causes, MS, nerve comp etc - MRI) • Aborting attacks - treatment of choice Tegretol with or without Baclofen • Severe constant attacks may be aborted with IV dilantin • Neurontin, Topamax, Lamictal, Depakote, Clonazepam

27. Thats All !