Headache & Dizziness: Emergency Setting

1. Headache & Dizziness: Emergency Setting Ma. Cristina Z. Macrohon, MD, MPH, FPNA General Neurology and Stroke

2. OBJECTIVES: • Focus evaluation of Headache and Dizzinesss in an emergency situation • Differential diagnoses • Immediate management

3. HEADACHE All aches and pains located in the head; discomfort in the region of the cranial vault.

4. Quality Severity Location Mode of onset Time-intensity curve Duration Associated Factors Dull, aching, sharply localized; pricking, stinging; tightness, pressure, bursting, sharpness, or stabbing; throbbing Degree; propensity to disturb sleep Paranasal sinuses, Vertex, biparietal, frontotemporal, occipito-nuchal region, supraorbital, infraorbital, ears, etc. Temporal profile Biologic Events, precipitating, aggravating, and relieving factors The Assessment

5. CLUES TO DIAGNOSIS • Site • Age and Sex • Clinical Characteristics • Diurnal Pattern • Life Profile • Provoking Factors • Associated Features

6. Migraine Tension type headache Cluster headache and other trigeminal autonomic cephalalgias Other primary headaches 5.Headache attributed to head and/or neck trauma 6. Headache attributed to cranial or cervical vascular disorders 7. Headache attributed to non-vascular intracranial disorder 8. Headache attributed to a substance or its withdrawal International Classification of Headache Disorders

7. 9. Headache attributed to infection 10. Headache attributed to disorders of hemoestasis 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 11. Headache or facial pain attributed to disorder of cranium,neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 12. Headache attributed to psychiatric disorders 13. Cranial neuralgias and central causes of facial pain 14. Other headache, cranial neuralgia, central or primary facial pain International Classification of Headache Disorders

8. Pain-sensitive structures in the head Intracranial Structures • Venous sinuses and afferent veins • Arteries of the dura mater and pia-arachnoid • Arteries of the base of the brain and their major branches • Parts of the dura mater near the large vessels

10. Extracranial Structures • Skin • Muscles • Periosteum of the skull • Mucosa • Extracranial arteries • Delicate structures of the eye, ear, nasal cavities and sinuses Nerves • Trigeminal • Facial • Glossopharyngeal • Vagus • Upper three cervical roots Pain-sensitive structures in the head

11. Non-sensitive structures 􀂑 Skull 􀂑 Pia-arachnoid and dura over the convexity of the brain 􀂑Brain parenchyma 􀂑 Ependyma 􀂑 Choroid plexuses

12. CLUES TO DIAGNOSIS • Site • Age and Sex • Clinical Characteristics • Diurnal Pattern • Life Profile • Provoking Factors • Associated Features

13. 1. Migraine without Aura SITE: - Frontotemporal Uni or bilateral AGE & SEX: Adolescents, young to middle aged adults, children, women CHARACTER: Throbbing, dull ache and generalized, scalp sensitive PATTERN: Upon awakening or later in the day DURATION: 4-24 H, sometimes longer

14. 1. Migraine without Aura LIFE PROFILE: Irregular intervals, weeks to months; tends to decrease in middle age and during pregnancy PROVOKING FACTORS: Bright light, noise, tension, alcohol; relieved by darkness and sleep ASSOCIATED FEATURES: Nausea and vomiting

15. 1. Migraine without Aura • TREATMENT: • Ergotamine; sumatriptan, NSAIDS • PREVENTION: • Propanolol or amitriptyline

16. 2. Migraine with Aura ASSOCIATED FEATURES: Scintillating lights, visual loss, and scotomas; unilateral paresthesias, weakness, dysphasia, vertigo, rarely confusion

17. AURAS Scintillating Scotoma

21. 3. Cluster Headache SITE: - Orbitotemporal; Unilateral AGE & SEX: Adolescent and adult males (90%) CHARACTER: Intense, nonthrobbing PATTERN: Nocturnal, 1-2H after falling asleep, occasionally diurnal

22. 3. Cluster Headache LIFE PROFILE: Nightly or daily for several weeks to months; Recurrence after many months or years PROVOKING FACTORS: alcohol ASSOCIATED FEATURES: Lacrimation, stuffed nostril, rhinorrhea, injected conjunctivum, ptosis

23. 3. Cluster Headache • TREATMENT: • Ergotamine before anticipated attack; Oxygen; sumatriptan • Methysergide, corticosteroids, verapamil, valproate, and lithium in recalcitrant cases

24. 4. Tension Headaches SITE: Generalized Mainly adults, both sexes CHARACTER: Pressure, tightness, aching PATTERN: Continuous, variable intensity DURATION: days AGE & SEX: weeks, or months

26. 4. Tension Headache LIFE PROFILE: one or more periods of months to years PROVOKING FACTORS: Fatigue and nervous strain ASSOCIATED FEATURES: Depression, worry, anxiety TREATMENT: Antianxiety and anti-depressant drugs

27. 5. Meningeal Irritation (Meningitis or SAH) SITE: Generalized, or bioccipital or bifrontal AGE & SEX: Any CHARACTER: Intense, steady deep pain, worse in neck PATTERN: Rapid evolution – minutes to hours LIFE PROFILE – single episode

28. 5. Meningeal Irritation (Meningitis or SAH) PROVOKING FACTORS: none ASSOCIATED FEATURES: Neck stiff on forward bending, kernig and brudzinski signs TREATMENT: Antianxiety and anti-depressant drugs

29. 6. Brain Tumor SITE: Unilateral or Generalized AGE & SEX: Any CHARACTER: Variable Intensity, May awaken patient, steady pain PATTERN: worse in a.m. increasing severity, lasts minutes to hours LIFE PROFILE – once in a lifetime: weeks to months

30. 6. Brain Tumor PROVOKING FACTORS: none; position ASSOCIATED FEATURES: Papilledema, vomiting, impaired mentation, seizures, focal signs TREATMENT: Corticosteroids, Mannitol, treatment for tumors

31. 7. Temporal Arteritis SITE: Unilateral or bilateral, usually temporal AGE & SEX: over 50 years, either sex CHARACTER: Throbbing, then persistent aching and burning, arteries thickened and tender PATTERN: Intermittent then continuous LIFE PROFILE –weeks to months

32. 7. Temporal Arteritis PROVOKING FACTORS: none ASSOCIATED FEATURES: Loss of vision, polymyalgia rheumatica, fever, weight loss, increased sedimentation rate TREATMENT: Corticosteroids

33. DIZZINESS Refers to different sensory experiences; rotation or whirling, nonrotatory swaying, weakness, faintness, lightheadedness, or unsteadiness; dizzy spells

35. The Vestibular Reflex System

36. VERTIGO VS DIZZINESS VS PSEUDOVERTIGO

37. Diagnosing Vertigo Px complaints of Dizziness Does the px has true vertigo? YES YES NO Intake of drugs causing vertigo? Diagnostic work up for lightheadedness, presyncope, or dysequilibrium YES NO Stop medications

38. NO Obtain hx, especially timing and duration, provoking and aggravating factors, assoc symptoms, and risk factors for CVD Perform PE with special attention to head and neck, cardiovascular, neurologic systems, and provocative dx tests Refine Differential Diagnosis Consider MRI for possible Central Cause: focal neurologic signs Other laboratory or Radiologic studies as indicated Refer to a specialist if diagnosis is in doubt or indicated by findings

39. Vertiginous Syndromes 1. Labyrinths Neurologic Findings: None Disorders of Equilibrium: Ipsilateral past pointing and lateral propulsion to side of lesion Types of Nystagmus: Horizontal or rotary to side opposite lesion, positional and position changing, fatigable. Hearing: Normal or conduction of neurosensory deafness with recruitment Diagnostics: Caloric testing

40. Vestibular nerve and ganglia Neurologic Findings: CN 8th and 7th palsy Disorders of Equilibrium: Ipsilateral past pointing and lateral propulsion to side of lesion Type of Nystagmus: Unidirectional positional, Hearing: sensorineuroal deafness sometimes Diagnostics: Radiography, CT, or Calorics

41. 3. Cerebellopontine Angle Neurologic Findings: Ipsilateral 5th, 7th, 9th, 10th,CN, ataxia, and increase ICP Disorders of Equilibrium: Ataxia and falling ipsilaterally Type of Nystagmus: Gaze-paretic, positional, coarser to side of lesion Hearing: sensorineuroal deafness without recruitment Diagnostics: CT, MRI, calorics, BAER, CSF

42. 4. Brainstem and Cerebellum Neurologic Findings: Multiple CN, brainstem tract signs, cerebellar ataxia Disorders of Equilibrium: Ataxia present with eyes open Type of Nystagmus: Coarse horizontal and vertical, gaze-paretic Hearing: normal Diagnostics: CT, MRI, Calorics

43. 5. Higher Connections Neurologic Findings: Aphasia, visual field, hemimotor, hemisensory, and other cerebral abnormalities, seizures Disorders of Equilibrium: No change Type of Nystagmus: absent Hearing: Normal Diagnostics: CT and EEG

44. PERIPHERAL VS CENTRAL VERTIGO

45. Meniere’s Disease • Triad of recurrent vertigo, fluctuating tinnitus, and deafness • Affects both sexes equally, 5th decade of life • Tx: • Rest in bed • Low salt diet + ammonium chloride + diuretics • Cyclizine, Meclizine, and transdermal scopolamine • Surgery

46. BPPV • Paroxysmal vertigo and nystagmus that occur only with the assumption of certain positions of the head. • Last < 1 minute but recur periodically for several days or months or years. • TX: • Dix-Hallpike Maneuver • Surgery • Medical

47. Vestibulopathy • Ototoxic effects of aminoglycosides; alcohol, anticonvulsants, anti-HTN, barbiturates, cocaine, diuretics, nitroglycerin, quinine, salicylates, sedatives/hypnotics • Cochlear hair cells and vestibular labyrinth • Disequilibrium and oscillopsia; unsteadiness of gait worse with eyes closed

48. Vestibular Neuronitis • Paroxysmal and a prolonged single attack of vertigo and by absence of tinnitus and and deafness • Young to middle-aged adults • Hx of antecedent upper respiratory infection of non-specific etiology • Tx: Methylprednisolone; antihistamne drugs, phenergan, clonazepam, scopolamine

49. Brainstem Origin • Auditory function is nearly always spared • Vertigo is less severe • Nystagmus may be uni-bidirectional, purely horizontal, vertical or rotatory, worsened by attempted visual fixation. • Associated CN, sensory, and motor tracts

50. Thank You 