Headache

1. Headache Rosen’s Chapters 17 and 105 November 9th, 2006 By George Filiadis

2. Epidemiology • 85% of the US population had significant headaches at least once • 3-5% of ED visits have as chief complaint headache • 50% accounts for tension headache while only 8% of headache has a potentially serious cause • Only 1% of headache in ED have life threatening cause(usually subarachnoid hemorrhage)

3. Rapid Assessment and Stabilization • Airway, Breathing, Circulation and Mental Status assessment in all critical patients with headache. • If there is change in mental status accompanied by headache, it must be assumed that cerebral circulation is compromised • The main principle of cerebral resuscitation focuses on 7 causes: lack of substrate (glucose, oxygen), cerebral edema, mass lesion intracranially, endogenous or exogenous toxins, metabolic alterations(fever, seizure), ischemia, or elevated intracranial pressure.

4. Pattern and onset of pain Activity at onset of pain History of head trauma History of HIV or immunocompromised state Character of the pain Location of head pain Intensity of pain Exacerbating or alleviating factors Associated symptoms and risk factors Prior history of headache Pivot Findings in history

5. Subarachnoid hemorrhage Shunt Failure Migraine Tumor/Masses/ Subdural hematoma Carbon MonoxidePoisoning, Mountain Sickness Temporal Arteritis Glaucoma/Sinusitis Tension headaches/ Cervical Sprain Cluster Bacterial Meningitis/ Encephalitis Anoxic Headache/ Anemia Hypertensive crisis Differential Diagnosis

6. Accounts for 1 million visits a year in the ED Onset is usually in second decade of life More prevalent among women Historically thought to be due to cerebral vasoconstriction and subsequent vasodilatation New beliefs indicate that changes in the serotonergic activity in midbrain are precursors to migraines Divided in migraine with and without aura Precipitants are nitrates, sleep deprivation, alcohol, hormonal changes, stress, chocolate, caffeine, oral contraceptives Migraine Headaches

7. Most common cause of migraine (80%) A.At least five attacks with the criteria B,C,D, and E B. Attack lasts 4 to 72 hours with or without treatment C. Has two of the following: unilateral location, pulsating quality, and moderate to severe intensity, aggravated by activity D. During headache associated with nausea/vomiting or photophobia/phonophobia E. History, physical and diagnostic tests that exclude related organic disease Migraine Without Aura (Common Migraine)

8. Migraine with Aura (Classic Migraine) • A. At least two attacks that fulfill criterion B • B.At least three of the four characteristics: 1)one or more reversible aura symptoms indicating focal cerebral or brainstem dysfunction 2) at least one aura develops gradually over more than 4 minutes and no single aura lasts longer than 60 minutes 3)headache begins during aura or follows with a symptom-free interval of less than 60 minutes • C. An appropriate history, physical, and diagnostic tests that exclude related organic disease.

9. Clinical Features • Most common aura is visual a)scintillating scotomas b)photopsias c)teichopsias d)blurred vision • Less common auras are somatosensory a)tingling or numbness b)motor disturbances c)cognitive disturbances

10. Ophthalmoplegic migraine is a rare condition associated with paresis of ocular nerves that may last days to weeks Hemiplegic migraine is characterized by episodic hemiparesis or hemiplegia as an aura that is slow or marching in progression and lasts 30 to 60 minutes Basilar artery migraine arises with an aura referable to brainstem and associated with near blindness, dysarthria, tinnitus, vertigo, bilateral paresthesias, or altered consciousness Status migrainosus persists longer than 72 hours and requires pain management Clinical Features

11. Treatment-Abortive

12. Treatment-Prophylactic • More than 2-3 episodes a month, prolonged attacks, severe and debilitating *b-blockers like propanolol *calcium channel blockers *tricyclic antidepressants *depakote *monoamine oxidase inhibitors

13. New thoughts for treatment of Migraines-Haldol • Monzilo PH, Nemoto PH.Acute treatment of migraine in emergency room: comparative study between dexamethasone and haloperidol. Arq Neuropsiquitr. 2004 june:62: 513-8 -29 patients who met HIS criteria for migraine: 14 pt received Haldol 5mg and 15 pt received decadron 4 mg . Conclusion. Pt who received haldol reached 50% reduction in pain in 30 min, while patients who received decadron reached the same level of anesthesia at 2 hrs.

14. New thoughts for treatment of Migraines-Haldol • Honkaniemi, Jari, Liimatainen Suvi, Rainesalo(2006) Haloperidol in the Acute Treatment of Migraine: A Randomized, Double-Blind, Placebo-Controlled Study. Headache: The Journal of Head and Face pain. 46 (5), 781-787 -40 patients were enrolled in a double-blind, placebo-controlled study. 80% of patients who were fiest treated with haldol showed significant relief while 79% of the patients treated with placebo first and subsequently with haldol felt significant pain relief.

15. Cluster Headache • More common in men • Associated with several episodes over 24 hrs that can last minutes up to 2 hrs • Clinical features include -unilateral sharp stabbing pain in eye -involves the distribution of CN V -30% of patients have partial Horner’s -eye is often injected, tearing

16. Cluster Headache-Treatment • High flow oxygen of 7-10 l/min • Sumatriptan, DHE • Prednisone tapering dose • Sphenopalatine nerve anesthesia with intranasal cocaine or lidocaine-controversial

17. Tension Headache • Most common type of headache • Higher prevalence in middle aged women • Usual frequency is 5 episodes per month • Clinical features include -tight, band-like discomfort around the head -intensity of pain is not severe and thus not debilitating -headache does not worsen with physical activity -coexisting anxiety and depression are common

18. Tension headache-Treatment • Aspirin, acetaminophen, NSAIDs • Exercise program • Nonpharmacologic regimen like massage, mediation, and biofeedback • Psychotherapy

19. Brain Tumor • In elderly, brain tumor is usually metastatic from lung or breast carcinoma. • Primary brain tumor are more common in adults younger than 50 years • HA is caused either by direct pressure on the brain or elevated ICP • Typical presentation is headache that worsens over over weeks to months • HA is usually present on awakening initially, then it becomes continuous.

20. Brain Tumor • HA is often worse with sneezing, bending, coughing. • Diagnostic tools include CT with IV contrast or MRI(best test)

21. Subarachnoid Hemorrhage (SAH) • Extravasation of blood in subarachnoid space activates meningeal nocireceptors causing occipital pain and meningismus. • SAH accounts for 10% of all strokes and is most common cause of death from a stroke. • Causes are saccular aneurysms (80%), blood dyscrasias, arteriovenous malformations, mycotic aneurysms, cavernous angiomas. • Risk factors include increased age,hypertension, smoking, excessive alcohol consumption and sympathomimetic drugs.

22. Subarachnoid Hemorrhage(SAH) • There is familial association of cerebral aneurysms with several diseases -autosomal dominant polycystic kidney disease -coarctation of the aorta -Marfan’s syndrome -Ehlers-Danlos Syndrome type IV • 1 to 4% of all ED patients with headache have SAH with 50% associated morbidity and mortality

23. Sudden “thunderclap” headache Can be associated with exertional activities Nausea/vomitng-75% Neck stiffness-25% Seizures-10% Meningismus-50% Subhyloid or retinal hemorrhages Oculomotor nerve pulsy with dilated pupil Restlessness and altered level of consciousness Clinical Features of SAH

25. Prognosis • It depends on neurological status at the time of presentation • Hunt and Hess scale • Grades I and II have good prognosis • Grades IV and V have grave prognosis

26. Diagnostic Studies • Emergent CT scan of head • CT is greater than 90% sensitive for acute bleeding-less than 24 hr • Sensitivity decreases to 50% by the end of the first week

27. Diagnostic Studies • When CT is negative a lumbar puncture should be performed • The CSF should be spun and the supernatant fluid should be observed for xanthochromia (develops after 12 hrs) • CSF xanthochromia with negative CT is diagnostic • Xanthochromia by spectophotometry is more sensitive

28. Diagnostic Studies • Patients with persistent bloody CSF without xanthochromia should go vascular imaging • Up to 90% of patients with SAH have cardiac arrhythmias or EKG findings suggestive of ischemia • Typical EKG changes include ST-T wave changes, U waves, and QT prolongation

29. Treatment • Airway, breathing, circulation and neurosurgical consultation. • Patients with Grade III SAH usually require endotracheal intubation • Nimodipine 60 mg PO or NG to lessen the chance of ischemic stroke due to vasospasm • Anticonvulsants for patients with evident seizure

30. Systemic inflammatory process of small and medium size arteries. Mean age of onset is 71 years, rare before 50 Headache is intermittent, worse at night or on exposure to cold Associated symptoms include jaw claudication, fever, anorexia, pain and stiffness in joints aka polymyalgia rheumatica On exam there is tenderness of temporal artery. It’s a medical emergency because long term sequelae is permanent visual loss. Diagnostic tests include ESR, CRP, LFTs, platelet count Definite diagnosis is by temporal artery biopsy Treatment is prednisone 60-120mg daily. Giant Cell Arteritis

31. Carotid and Vertebral Artery Dissection • Most common cause of stroke in persons younger than 45 years. • Associated with sudden neck movement or trauma following neck torsion, chiropractic manipulation, coughing, minor falls, MVA. • The pathologic lesion is an intramural hemorrhage in the media of the arterial wall that can be subtle in the early phase leading to thrombus formation over time with emboli or significant enough to occlude the vessel. • Patients can present with stroke symptoms days to years after dissection.

32. Carotid artery Dissection • Classic triad includes unilateral headache, ipsilateral partial Horner’s syndrome, and contralateral hemispheric findings like aphasia, neglect, visual disturbance or hemiparesis. • Older age, occlusive disease, stroke on initial presentation has worse prognosis • Diagnosis is via CT angio, MRI/MRA

33. Vertebral Artery Dissection • Unilateral posterior headache, and neurological findings like vertigo, ataxia, diplopia, hemiparesis, and unilateral facial weakness, tinnitus • Diagnosis is same as in carotid dissection • Treatment includes early anticoagulation followed by antiplatelet therapy

34. Also known as Pseudotumor Cerebri. Commonly seen in young obese women o Predisposing factors include anabolic steroids, oral contraceptives, tetracyclines, Vitamin A Caused by increased brain water content and decreased CSF ouflow. Most common symptom is generalized headache. Eye movement, bending forward or Valsava may worsen headache On exam patients have papilledema and visual defects, including an enlarged blind spot followed by loss of peripheral lesion. Idiopathic Intracranial Hypertension

35. Idiopathic Intracranial Hypertension(IIP) • Treatment -stop offending med -lower CSF production with acetazolomide and furosemide. -steroids -repeat LPs -ventricular shunt if with impending visual loss.

36. Estimated that 30-50% of 2 million closed head injuries per year develop headache. Associated with dizziness, fatigue, insomnia, irritability, memory loss, and difficulty with concentration. Acute PTHA develops hours to days after injury and may last up to 8 weeks. Chronic PTHA may last from several months to years. Patients have normal neurological examination and imaging Treatment for acute PTHA is symptomatic while for chronic PTHA, adjunct therapies include beta-blockers and antidepressants. Posttraumatic Headache(PTHA)

37. Sudden onset of eye pain radiating to head, ear, teeth, and sinuses. Visual symptoms include blurriness, halos around lights, and scotomas. Nausea and Vomiting Due to congenital narrowing of the anterior chamber angle that leads to elevated intraocular pressure (IOP) Medications that elevate IOP include mydriatics, sympathomimetics Acute Glaucoma

38. Acute Glaucoma • Physical exam shows a red eye with a fixed middilated pupil and shallow anterior chamber (separates it from cluster HA) • IOP in the range of 60 to 90 mmHg ( not found in iritis) • Treatment includes topical miotics, b-blockers, carbonic anhydrase inhibitors, optho consult

39. Most common complication following lumbar puncture (up to 40%) Most common in 18 to 30 year old patients It can last up to 5 days Bilateral throbbing HA that worsens with upright position Thought to be due to persistent leak of CSF that exceeds its production Treatment includes rest, fluids, and blood patch, caffeine or theophylline for persistent HA Postdural Puncture Headache

40. HA is common complaint in meningitis, brain abscess, encephalitis or AIDS Diagnostic tools include CT of head and LP Intracranial Infection

41. Elevated blood pressure is not as important in HA as the rate by which the blood pressure increases Nonetheless, HA with severe HTN is well documented especially in hypertensive encephalopathy Treatment is directed at lowering blood pressure slowly HA may last for days until brain edema has resolved Hypertensive Headache

42. Medication use, abuse or withdrawal s the cause. Common in patients with chronic headache disorders like migraine or tension-type. Most common meds include ASA, NSAIDs, Tylenol, barbiturate-analgesic combinations, caffeine, and ergotamine Patients build tolerance to the meds and subsequently require higher doses for symptomatic relief. Treatment includes withdrawal of the overused medications Medication-Induced Headache

43. Carbon Monoxide Poisoning • Usually gradual, subtle, dull, nonfocal throbbing pain associated with nausea, chest pain. • Symptoms may wax and wane as patients may enter and leave the area of carbon monoxide • Exposure to engine exhaust, old or defective heating systems, most common in winter months. • Non focal neurological exams. • Diagnosis is made by elevated carboxyhemoglobin • Treatment is oxygen

44. High Altitude Headache • Main symptom of Acute Mountain Sickness • Can occur at altitudes higher than 5000 feet in unacclimatized individuals. • HA is throbbing, located in temporal or occipital area and worsens at night or early in the morning. • Treatment includes supplemental oxygen and descent to a lower altitude.

45. Key Concepts • HA is a challenging yet common complaint in ED • Diseases that we cannot afford to miss are SAH, CO poisoning, temporal arteritis, bacterial meningitis/encephalitis • Be liberal with use of CT • Remember CT doesn’t rule out SAH-need LP. • If CT and LP are negative think of temporal arteritis if older than 50 years, and CO poisoning. • Don’t forget the eyes!