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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:
    • subarachnoid haemorrhage - classically, a thunderclap onset in occipital region
      • subdural haematoma 
        • may be chronic in the elderly after a forgotten fall; decreased mental state usually more significant than headache;
        • have a low index of suspicion in any elderly patient after a fall, especially if they are on anticoagulants such as aspirin or warfarin.
      • extradural haematoma - usually a history of trauma with LOC
      • brain tumour - frontal/vertex headache if above tentorioum; occipital headache if subtentorial; pain on wakening; worse on Valsalva;
      • intracerebral abscess (rare)
      • venous thrombosis (rare)
    • toxic metabolic headaches:
      • fever > 38.8degC
      • influenza typically presents with severe headaches and then cough
      • hypoxia or hypercapnia are potent cerebral vasodilators
      • acute anaemia due to blood loss
    • hypertensive headaches
      • a throbbing occipital headache, usually do not occur unless diastolic > 130mmHg
    • acute glaucoma:
      • orbital pain with N/V and cornea may be oedematous with pupil mid-position, decreased acuity & raised i/ocular pressure.
    • temporal arteritis
      • mainly women aged > 50yrs; this requires starting on prednisolone 60-80mg/d ASAP to prevent optic neuritis and bilateral blindness.
      • untreated, if blindness occurs in one eye, blindness will occur in the other eye within 1-20 days in 75%.
      • maintenance dose of prednisolone usually recommended for a year or more with periodic ESR to assess progress.
  • the majority of patients have headaches due to less worrying conditions such as:
    • tension headache
    • cervicogenic headache
      • 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
    • post-concussion headache
    • 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
      • 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:
    • high altitude - eg. non-acclimated climbers at altitudes greater than 3000-3600m
    • drug-induced
      • vasodilators such as GTN
      • even inhaled Rx for asthma such as LABA with setroids which can cause headaches and nasopharyngitis
    • 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:

some patients will require immediate treatment within minutes:

  • the patient with strongly suspected bacterial meningitis:
    • urgent IV antibiotic Rx 
    • +/- IV fluid/inotrope support if evidence of septic shock - purpura, poor capillary refill or hypotension.
    • investigations such as CT and LP as time allows
  • the patient with decreased mental state:
    • assessment of A,B,C's +/- airway support (eg. intubation if GCS < 8)
    • FBE, U&E, RBG, dextrostix, +/- blood cultures if high fever, +/- ABG's.
    • rapid assessment for localising neurology (eg. stroke, SAH) 
    • rapid assessment for possible sepsis with early IV antibiotics/antivirals administered if clinically indicated.
    • early CT scan once stabilised, and if normal, then LP may be indicated, although this can usually be delayed.
    • differential diagnosis includes:
      • intracranial event:
        • stroke, SAH, meningitis, encephalitis (eg HSV), brain tumour
        • intracranial thrombosis,  
        • traumatic brain injury - concussion, subdural or extradural haemorrhage
      • general conditions:
        • hypertensive encephalopathy
        • drug overdose
        • metabolic conditions - hypoglycaemia, DKA, hyperosmolar coma, hyponatraemia, hypoxia, hypercapnia
  • the patient with neurologic symptoms:
    • although hemiplegic migraine may be the cause, one needs to exclude a stroke, space occupying lesion or aneurysm
    • early CT brain 
    • do not use ergotamine or sumatriptan as these vasoconstrict and may exacerbate ischaemia

the essential problem is which patients need a CT +/- LP and which can be just managed symptomatically and discharged home?

  • see below for indications for brain CT scan.

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:

  • send bloods for FBE, RBG (+/- blood cultures if high fever)
  • before embarking on CT brain and lumbar puncture (LP) (assuming there is true neck stiffness not just soreness):
    • consider CXR to exclude pneumonia as a cause
    • consider painful Cx lymphadenopathy as cause of neck pains - could it be infectious mononucleosis?

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:

  • patients with PH migraine who present with their typical features of migraine and no red flags for other conditions should be moved to a quiet room with low level of lighting and treated for migraine depending on severity of attack, medications already used and contraindications

analgesia for the patient with non-migrainous benign headache

indomethacin responsive headaches

  • these headaches respond well to indomethacin but not as well to other non-steroidal anti-inflammatory drugs (NSAIDs)
  • 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
  • sudden onset headache (esp. occipital) suggestive of sub-arachnoid haemorrhage:
  • headache with acute unexplained impaired mental state or new neurology
  • possible meningitis:
    • eg. meningism, fever, headache
    • empirical antibiotics, then CT ASAP & if normal, usually requires LP
  • head trauma with reasonable risk of intracranial haemorrhage such as:
    • patient on anticoagulants
    • ongoing vomiting
    • decreased mental state
    • penetrating injury or possible fracture base of skull
    • see under head injury in the adult patient for more details
  • 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
      • NB. ask about substance misuse
    • 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.
  • new onset seizures with headache
  • HIV / AIDS patients with new type of headache
  • 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