How to approach a patient with headache in ED
A 30 year old patient comes to the emergency department with history of headache.
How to approach this patient in ED & what important points needs to be evaluated in this patient.
Approach:
-Place the patient on automated BP monitoring ,ECGmonitoring& pulse oximetry-Vital signs: temperature, blood pressure, pulse, and 02 saturation
Detailed History:
High risk patients:
o Age >50 years, with a new or worsening headache
o Sudden onset of worse severe headache in the life (raises concern for subarachnoid
hemorrhage).
o History of head trauma (even in the last 2 weeks)
o Associated symptoms as:
o Fever, neck stiffness, vomiting and photophobia (raises concern for meningitis)
o Fever and behavior changes (raise concern for encephalitis).
o Confusion, Convulsion or Neurological deficit (raise concern for: stroke or, brain
tumor)
o Vertigo or ataxic gait o Visual changes: Specify _
o Change in headache quality, or progressive headache worsening over
weeks/months
o Medication History (warfarin, and antiplatelet agents) (increase the risk for
intracranial hemorrhage)
o Medication history (chronic steroids or immunosuppressants drugs) (increase risk
of CNSinfections)
o Medication history of oral contraceptive pills (increase risk of venous sinus
thrombosis)
o Pregnant Women: Preeclampsia should be considered in pregnant women after
20th week
o Venous sinus thrombosis should be considered as a cause of headache during
pregnancy, the postpartum state, and hypercoagulation state as (SLE,vasculitis)
Low risk patients:
o Facial pain (raise concern of sinusitis or dental infection)
o Temporal area pain increase with jaw movement (raise concern of temporal
arteritis)
o Medical history as uncontrolled hypertension associated with hypertensive
urgency
o Medication history of nitroglycerin or carbon monoxide poisoning
o History Use of cocaine, amphetamine, and alcohol
o Prior Headache History suggestive of migraine, tension, or cluster-type headaches,
and response to specific therapy
o Family History of aneurysm or sudden death in first-degree relatives (raises the
suspicion for intracranial aneurysm)
DETAILED EXAMINATION:
o Complete Neurologic Examination includes:
o Mental status assessment
o Speech
o Gait
o Pupillary examination (for asymmetry or ptosis)
o Cranial nerve examination
o Motor examination to detect extremity weakness
o Deep tendon reflex examination
o Coordination testing (to detect cerebellar lesions)
o Examination of the Eye: to exclude angle-closure glaucoma or 3rd cranial nerve palsy
o Examine the ears, nose, and throat to identify otitis media and sinusitis
o Examination of the Head and Neck: Meningismus is an important clinical clue to
Meningitis.
o Palpate for tenderness over the temporal arteries to assess for possible temporal
arteritis
Important Differential Diagnosis to consider in ED
1. SUBARACHANOID HEMORRHAGE (SAH)
Following are strongly and reliably associated with SAH
- Sudden onset of headache
- Maximal at onset
- Hx of recent similar headache (Sentinel bleed)
- Age >40
- Neck Stiffness or pain
- Onset of headache on exertion
- Vomiting
- Witnessed loss of consciousness
- Elevated Bp of > 160/100
Also consider the following symptoms
- Stroke like symptoms
- Seizure
- 3rd Cranial Nerve palsy from mass effect
- 6th Cranial Nerve Palsy with diplopa
- Subhyaloid Hemorrhage (Terson Syndrome: Dense red on fundoscopy)
- Meningismus
Risk factors:
- Family history of Cerebral bleed
- History of SAH
- Family history of Polycystic kidney disease
- Collagen vascular disease
- Hypertension
- Binge Drinking
- Use of cocaine or smoking
- Onset of headache during exertion
- Presyncope or syncope with headache
Workup of SAH:
ECG::
- Changes occur in 50-100% of patients due to neurogenic myocardial stunning or coronary vasospasm.
- Deep, wide precordial T‐wave inversion, bradycardia, and prolonged QT
- Imp::; don't anticoagulate these patients considering the above findings as ACS
CT Brain:
- Sensitive 95% within 12 hours
- Sensitive 85 % after 1 day
- Sensitive 50% after 1 week
Lumber Puncture:
- Lumber puncture is still standard. However 25% are at increased risk of Post LP headache, Infection and neurological damage.
- Important points to consider for LP here as per recommendations:
- Don't wait till 12 hours after onset for Xanthochromia to be reliably present as then the patient will also be at risk of fatal bleed.
- True positive tap may be hidden in Traumatic tap, so if you wanna say it a true negative tap only if RBC are <5 in tube 4 or a decrease in 25% of RBC from tube 1 to 4.
- Opening pressure should be done as it may be elevated in SAH but will not rise in Traumatic tap, can rise in BIH, CVT
- Post LP headache classically occurs day 3 and are worse when not suppine, are result of CSF leaking from dura or it can be called post dural puncture headache PDPH, which is not shown to be helped with bed rest or caffeine intake but only by Blood patch of patient's own blood. Post LP headache can be minimised by use of smaller needle like 25G and using non cutting needles. (By Dr. Anton)
- If unsuccessful LP or refused by patient then do CT angio to find out if any aneurysm identifiable
Management of SAH:
- Involve Neurosurgeon to consider the target BP if MAP is more than 100-110
- To prevent rebleed treat hypertention if MAP is more than 100 to 110 for few hours and can use IV labetolol 20mg iv bolus then 1-2mg/min infusion not to exceed 300mg or 40-80mg iv q10min with blood pressure monitoring every 5-10min. No dosage alteration in renal or hepatic impaired patients been recommended.
- Oral Nimodipine 60mg p/o or Per NG to prevent vasospasm and subsequent cerebral infarct, every 4-6 hours , should be started within 24hours of presentation. It comes in 30mg gel capsules or 30mg/10ml or 60mg/20ml oral solution. Dosage should be decreased to 30mg in hepatic impairment, closely monitor BP (decreases BP) and HR(arrhythmia).
- Consider starting anti-epileptic which can occur in SAH patients
2. MIGRAINE:
Beware of self diagnosis brought in by patient.
To diagnose as a case of Migraine patient should be diagnosed by physician with history of recurrent similar symptoms with similar intensity and character.
Classical Migraine history will be as follows and can be remembered by Mnemonic of POUND
- Pulsatile quality headache, 4-72Hours duration onset, Unilateral pain, Nausea and Disabling intensity of headache. Can be associated with phono and photophobia. 4 out of 5 features are usually present in POUND Mnemonic.
- Can also present with bilateral colored tunnel vision instead of unilateral flashes and floaters white in color and like a black curtain falling down in cases of vitreous and retinal detachment respectively.
- SSNOOP mnemonic for red flags: Systemic signs (fever, weight loss), Secondary risk factors (immuno‐ compromised status, HIV), Neurological signs (speech deficit, cranial nerve abnormalities), Onset – abrupt, Older age (>40yo), Progression of symptoms (By Dr. Lucas)
Management::
- Inj Metoclopramide 10mg IVI slow infusion over 15-20min or inj prochlorperazine over 15min IVI
- Inj Diphenhydramine 50mg IVI in case of development of extrapyramidal symptoms
- Inj Dexamethasone 10-15mg IV or P/O on discharge (to prevent rebound 72 hrs headache) by decreasing the inflammation of the blood vessels in the brain.
- Naproxen 500mg on discharge shown to be equal effect of Triptans (reported to cause chest tightness), give to people who don't have CVS disease.
3. SPONTANEOUS CERVICAL ARTERY DISSECTION:
Cervical artery dissection is a tear in cervical artery (carotid or vertebral artery) with development of intramural hematoma resulting in stenosis, occlusion or aneurysmal dilation.
Cervical artery dissection usually occurs with minor trauma such as hyperextension of neck during shaving, while driving checking upon blind spot, roller coaster ride, boxing or even coughing in case of connective tissue disease.
Evaluation:
Classic Triad of Carotid Artery Dissection: although only 1/3 of patient present with all 3
- Unilateral pain of head, neck or face
- Partial Horner Syndrome (ptosis, miosis)
- Cerebral or retinal ischemia or TIA symptoms
Dissection of Vertebral artery:
- May present with posterior neck pain
- Headache
- Vertigo
- Ataxia
- Swallowing difficulty
Diagnosis is by:
- CT angiography
- Duplex Scan
- MRA
Management:
- Antithrombotic therapy for at least 3-6 months for a patient with ischemic stroke or TIA
- Endovascular stenting
- Surgical Repair
4. Cerebral Venous Sinus Thrombosis:
Can present in young patients, women more than men.
Symptoms can range from:
- Headache (thunderclap to subacute)
- Seizure
- Stroke like symptoms
- Papilledema, orbital chemosis, proptosis
Risk Factors:
- Thrombophilias
- OCP Use
- Pregnancy
- Malignancy
- Sinusitis
Evaluation:
- CBC with coagulation profile
- D Dimer (not reliable)
- MRV or CTV(empty delta sign)
- Plain CT (Delta sign, Hemorrhagic infarct grey white matter junction, hyperdense cervical vein or dural sinus)
- LP may show increased opening pressure
Management:
-Despite risk of hemorrhagic transformation treatment with LMWH or unfractionated heparin shown to reduce Death and dependency.
5. IIH:
Same spectrum of CVT with LP showing increased opening pressure with papilledema and usually young patients, more in females on OCP, but management differs in use of diuretics instead of anticoagulation
6. Carbon monomoxide poisoning:
Multiple patients
Wood burning stove gathering
CT may show bilateral hypodensities
7. Glaucoma: Photophobia, Eye exam mandatory
8: Temporal Arteritis: Other systemic sign and symptoms of disease, PMR, jaw claudication, Blurring of vision, retinal ischemia, check ESR)
9. Hypertensive encephalopathy ( Altered LOC, Papilledema)
Others::
- Meningitis, encephalitis
- Tumor
- Pre-eclampsia
- Drugs
- Toxins
- Substance abuse, etc
Disclaimer: This don't replace guidelines, follow local protocols.
