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Headache Jc
 

Headache Jc

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    Headache Jc Headache Jc Presentation Transcript

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