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

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

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)

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

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)

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

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

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?

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

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

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

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

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

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

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

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

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

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

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%

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

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

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

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

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