Headache Jc

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Headache Jc

  1. 1. Sudden-onset headache Clinical Approach Joseph Cherian P. Asst Professor of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram.
  2. 2. Epidemiology <ul><li>1-2% of visits to the emergency department </li></ul><ul><li>4% of visits to the physician’s office </li></ul><ul><li>Most have primary headache disorders </li></ul><ul><li>Among all patients with headache in an ED, 1% will have SAH </li></ul><ul><li>In patients with the worst ever headache of their life, and normal neurological exam, 12% will have SAH </li></ul>
  3. 3. Pain-sensitive structures in the head <ul><li>Blood vessels </li></ul><ul><li>Meninges </li></ul><ul><li>Bone </li></ul><ul><li>Cranial nerves- V, VII, IX, and X </li></ul><ul><li>Scalp and muscles </li></ul><ul><li>Nerve roots, sinus mucosa and teeth </li></ul>
  4. 4. Working classification of headache <ul><li>Migraine (10% prevalence) </li></ul><ul><li>Tension-type headache(30-80% prevalence) (CTH-2%) </li></ul><ul><li>Other headache (includes cluster HA and secondary headaches) </li></ul>
  5. 5. Secondary headache disorders <ul><li>Stroke, SAH </li></ul><ul><li>Tumour </li></ul><ul><li>Infection </li></ul><ul><li>Systemic disorders- thyroid disease, HT, pheochromocytoma. </li></ul><ul><li>Temporal arteritis </li></ul><ul><li>Ophthalmological and ENT causes. </li></ul><ul><li>Traumatic </li></ul>
  6. 6. Danger signals <ul><li>First or worst headaches </li></ul><ul><li>Headache on exertion, early morning, or nocturnal </li></ul><ul><li>Progressive headache </li></ul><ul><li>New onset headache in adult >50 years old </li></ul><ul><li>Abnormal physical or neurological findings (fever, stiff neck) </li></ul>
  7. 7. Sudden onset headache-causes <ul><li>Crash migraine </li></ul><ul><li>Cluster </li></ul><ul><li>Benign exertional </li></ul><ul><li>Posttraumatic </li></ul><ul><li>Vascular disorders-stroke, SAH, TA, dissection, CVT, acute HT </li></ul>
  8. 8. Sudden-onset headache -causes(contd) <ul><li>Nonvascular IC disorders- hydrocephalus, IIH, IC hypotension, tumour, pit.apoplexy </li></ul><ul><li>Acute intoxications </li></ul><ul><li>Noncephalic infections </li></ul><ul><li>Cephalic infections </li></ul><ul><li>Disorders of eyes </li></ul><ul><li>Cervicogenic </li></ul>
  9. 9. History taking <ul><li>When did the headache start? </li></ul><ul><li>How long before it reaches maximum intensity? </li></ul><ul><li>Have you had similar headaches before? </li></ul><ul><li>Where does the head hurt? </li></ul><ul><li>Do you have other symptoms? </li></ul><ul><li>What makes it worse? </li></ul><ul><li>What makes it better? </li></ul>
  10. 10. Examination <ul><li>Fever, lymphadenopathy, elevated BP </li></ul><ul><li>Skin- rash, neurocut markers </li></ul><ul><li>Tenderness-sinuses, TM joint </li></ul><ul><li>Temporal and carotid arteries </li></ul><ul><li>Neurological exam: pupils, eye signs, papilloedema, pronator drift, s/o meningeal irritation </li></ul>
  11. 11. Subhyaloid hemorrhage
  12. 12. Physical findings in SAH <ul><li>Nuchal rigidity </li></ul><ul><li>Altered consciousness, </li></ul><ul><li>Papilloedema, retinal and subhyaloid hemorrhage, 3rd and 6th nerve palsy, </li></ul><ul><li>Bilateral leg weakness, abulia, </li></ul><ul><li>Nystagmus, ataxia, </li></ul><ul><li>Aphasia, hemiparesis, left-sided visual neglect </li></ul>
  13. 13. Diagnosis of SAH <ul><li>25-51% of patients receive an incorrect diagnosis </li></ul><ul><li>91% of those with correct diagnosis have a favorable outcome at 6 weeks Vs 53% with an incorrect diagnosis </li></ul><ul><li>Median delay in diagnosis(4 studies): 3 - 14 days </li></ul>
  14. 14. Reasons for misdiagnosis of SAH <ul><li>Failure to appreciate the spectrum of clinical presentation </li></ul><ul><li>Failure to understand the limitations of CT </li></ul><ul><li>Failure to perform and correctly interpret the results of LP </li></ul>
  15. 15. Indications for neuroimaging <ul><li>First or worst headache </li></ul><ul><li>Progressive or CDH </li></ul><ul><li>Side-locked headache </li></ul><ul><li>Headaches not responding to treatment </li></ul><ul><li>New onset headache in patients with cancer, HIV infection, or age >50 yrs </li></ul><ul><li>Associated fever, stiff neck, neurological deficits </li></ul>
  16. 16. CT Vs MRI <ul><li>Preferred in SAH ICH </li></ul><ul><li>Posterior fossa lesions </li></ul><ul><li>CVT </li></ul><ul><li>SDH, EDH </li></ul><ul><li>Meningeal disease </li></ul><ul><li>Cerebritis and abscess </li></ul><ul><li>Pituitary pathology </li></ul>
  17. 18. SAH
  18. 21. Imaging in pts with headache and normal neurological exam <ul><li>Benefits- CT MRI </li></ul><ul><li>Migraine 0.3% 0.4% </li></ul><ul><li>Any HA 2.4% 2.4% </li></ul><ul><li>Relief of anxiety 30% </li></ul><ul><li>Harms-iodine reaction </li></ul><ul><li>Mild 10% </li></ul><ul><li>Death 0.002% </li></ul><ul><li>Claustrophobia </li></ul><ul><li>Cost Frishberg 1994 </li></ul>
  19. 22. Probability of detection of SAH on CT after the initial event <ul><li>Day 0 95% </li></ul><ul><li>Day 3 75% </li></ul><ul><li>1 week 50% </li></ul><ul><li>2 weeks 30% </li></ul><ul><li>3 weeks almost 0% </li></ul><ul><ul><ul><ul><ul><li>Evans RW 1999 </li></ul></ul></ul></ul></ul>
  20. 23. L.P in evaluation of headache <ul><li>Suspected SAH if CT is negative </li></ul><ul><li>(Deterioration after LP in patients with clots on CT or a dilated pupil) </li></ul><ul><li>Start antibiotics in patients with suspected meningitis, while waiting for CT </li></ul><ul><li>CSF pressure should be measured </li></ul><ul><li>Distinguish traumatic tap from true hemorrhage </li></ul>
  21. 24. L.P in evaluation of headache <ul><li>First or worst headache - SAH, meningitis </li></ul><ul><li>Headache with features s/o infection - meningitis /encephalitis </li></ul><ul><li>CVT, IIH - elevated CSF opening pressure </li></ul><ul><li>Orthostatic headache with diffuse meningeal enhancement on MRI - Low CSF pressure syndrome </li></ul>
  22. 25. Probability of detecting xanthochromia in CSF with spectrophotometry after SAH <ul><li>12 hours 100% </li></ul><ul><li>1 week 100% </li></ul><ul><li>2 weeks 100% </li></ul><ul><li>3 weeks >70% </li></ul><ul><li>4 weeks >40% </li></ul>
  23. 27. Angiography <ul><li>In proven SAH- 4 vessel angio(DSA) to identify source and r/o multiple aneurysms </li></ul><ul><li>Initial arteriogram negative in upto 16% of SAH </li></ul><ul><li>MRA detects 90% of saccular aneurysms of >5mm </li></ul><ul><li>Spiral CT angio detects 85% of saccular aneurysms </li></ul>
  24. 28. Thunderclap headache <ul><li>Sudden severe headache with max intensity within 1 minute </li></ul><ul><li>Normal CT scan </li></ul><ul><li>Normal CSF study </li></ul><ul><li>180 patients followed up for 1- 3 years. None developed SAH. </li></ul><ul><ul><ul><ul><ul><li>Wijdicks 1988, Markus 1991, Linn 1994 </li></ul></ul></ul></ul></ul>
  25. 29. Thunderclap headache <ul><li>Primary causes- Migraine, benign thunderclap headache, benign orgasmic headache </li></ul><ul><li>Secondary- unruptured saccular aneurysm, cerebral vasospasm, CVT, arterial dissection, pituitary apoplexy, occipital neuralgia </li></ul><ul><ul><ul><ul><ul><li>Evans RW 2000 </li></ul></ul></ul></ul></ul>
  26. 30. Thank You

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