headache
headache
introduction:
patients with headache as a prime feature are a worrying group of patients as there are a number of potentially life threatening or morbid conditions that, although uncommon, are easily missed:
the majority of patients have headaches due to less worrying conditions such as:
tension headache
cervicogenic headache
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occurs in up to 4% of the population, and perhaps a quarter of those who have had neck trauma
up to 70% are due to issues with the C2-3 zygapophyseal joint (innervated by C2 and C3 which can give referred pain to occiput, fronto-temporal and perioribital regions), with the atlanto-axial joint (innervated by C1 and pain is referred to occiput) being the 2nd most common aetiologic focus
suggestive features include palpably painful upper cervical joints and restricted range of neck extension
lesions cannot be detected on either CT and MRI but these may be done to exclude other pathology
many patients also have tension headaches and migraine headaches
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analgesic abuse headaches
post-ictal headache
cluster headaches:
mainly young adult males, recurrent, peak pain 10-15min after onset and lasts 45-60min, unilateral, excruciating, non-throbbing and usually retro-orbital with ipsilateral nasal stuffiness and lacrimation. Often nocturnal;
10min of oxygen at 5-8L/min may abort attacks in 70%
instillation of 4% lignocaine into ipsilateral nostril is useful
consider verapamil
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BUT be aware that ~20% of patients having CT brain for headache or mild CHI will have a CT report of “chronic sinusitis” - this finding without acute URTI should probably NOT warrant Rx and is probably NOT the cause of an acute headache
2)
coital headache
usually severe, sudden onset headache associated with orgasm and last a few hours
risk factor tends to be sedentary lifestyle as a regular exercise routine tends to reduce incidence
be aware that SAH should still be excluded as SAH can occur during coitus
post-LP headaches:
usually starts within 48hrs (but not within 1hr) of lumbar puncture or epidural procedures although may be delayed for up to 14 days.
bicranial, pulsatile, worse in upright position and on movement, median duration is 5 days with early onset usually more severe and longer lasting.
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high altitude - eg. non-acclimated climbers at altitudes greater than 3000-3600m
drug-induced
benign intracranial hypertension (pseudotumour cerebri)
usually, young, obese female with amenorrhoea or irregular cycles or on tetracyclines;
papilloedema present; CT shows slit-like ventricles and no mass effect;
trigeminal neuralgia - usually age > 50yrs; brief, excruciating attacks of facial pain;
obstructive sleep apnoea headaches - usually morning headaches
clinical approach in the ED:
the essential problem is which patients need a CT +/- LP and which can be just managed symptomatically and discharged home?
the patient with new onset headache aged > 50yrs:
this is unlikely to be migraine
FBE, ESR, U&E, RBG, check BP
if ESR high, consider temporal arteritis, meningitis, sinusitis, other infection (eg. pneumonia)
consider CT brain
the patient with mild meningism, fever:
the patient with headaches for weeks:
the longer the duration of headache without change in its severity or character, the more benign it is likely to be.
increasing frequency, severity, especially if nocturnal and/or associated with vomiting, the more one should consider an intracranial tumour with rising intracranial pressure as a cause - do not do LP on these patients - do a CT brain (although this does not exclude raised ICP) and look for CLINICAL signs of raised intracranial pressure and consult with seniors.
the migraine patient:
analgesia for the patient with non-migrainous benign headache
1st line: paracetamol +/- codeine, rest, Rx cause
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3rd line: aspirin with oral maxolon +/- codeine
4th line: iv maxolon 20mg + antihistamine appears to be better than parenteral ketorolac and probably safer
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indomethacin responsive headaches
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paroxysmal and continuous hemicranias
valsalva-induced headache
primary stabbing headache or ice-pick headache
a select group of trigeminal-autonomic cephalgias
hypnic headache
indications for CT brain Ix of headache in adults patients in ED:
CT brain (non-contrast) while in ED:
see also indications for head CT scan for non-“headache” patients
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headache with acute unexplained impaired mental state or new neurology
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head trauma with reasonable risk of intracranial haemorrhage such as:
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migraine” patient with alarm symptoms & signs that may warrant a CT scan (EEG is seldom helpful):
aura symptoms always at same side of body (should alternate)
aura symptoms with acute onset without spread or with either very brief (<5min) or prolonged (>60min) duration
sudden change in migraine characteristics
sudden, substantial increase in attack frequency
onset above age 50yrs
aura without headache
high fever
abnormal neurologic examination:
ie. new focal deficit, altered mental status, or altered cognitive function
increases probability of abnormal CT by 3x and a PPV of 39%
CT should be performed
ASAP.
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age > 60 yrs with acute or recent onset unexplained headache
long standing headaches without past CT scan to exclude pathology, particularly if new features such as vomiting that may indicate rising intracranial pressure or complication of an intracerebral tumour.
headache.txt · Last modified: 2019/06/08 23:18 by wh