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Dr. Nawaf Al-Amri M.D
Senior Resident
Saudi Board Of Emergency Medicine
We’re Going To Cover The Following
- Basics Of Headache : The Anatomy & Physiology Of The Pathology
- Headache Epidemiolog...
What Is Headache ?
• Headache: is pain anywhere in the region of
the head or neck.
• Pain in the head and neck may easily ...
Pathophysiology Of Headache
• Brain tissue doesn’t feel pain i.e no pain
receptors in the actual tissue .
• Rather, the pa...
Pathophysiology Of Headache
• Cranium (Periosteum Of The Skull).
• Meninges.
• Nerves.
• Vessels.
• Eyes.
• Ears.
• Sinuse...
Pathophysiology Of Headache
• The ability of the patient to specifically localize
head pain is often poor if the area invo...
Pathophysiology Of Headache
• Much of the pain associated with headache,
particularly with vascular headache and
migraines...
Pathophysiology Of Headache
• The Nociceptors may be stimulated by :
• Inflammation Or Infection.
• Stretching , Tension ,...
Pathophysiology Of Headache
• It has been suggested that the level
of endorphins may have a great impact on the
sensation ...
Pathophysiology Of Headache
* Two Suggested Theories For The Pathophysiology Of
Headaches / Migraines :
• Old : The Vascul...
Pathophysiology Of Headache
- New : The Neurological Theory :
- Headaches/ Migraines are triggered by a complex
series of ...
Headache Epidemiology
• Headache as a primary complaint represents
between 3 and 5% of all (ED) visits.
• More common in F...
Headache Epidemiology
• Less than 1% of patients who present to the
ED with headache have Life-Threatening
secondary cause...
Headache Epidemiology
• These percentages can create a False sense of
security.
• The most commonly encountered life threa...
Headache Epidemiology
• It is estimated that between 25 and 50% of SAH
are missed on the first presentation.
• It Is noted...
Headache Epidemiology
- Most common type of Primary Headache in
ED is TENSION > MIGRAINE > CLUSTER.
- Factors predisposing...
Emergency Medicine Attitude Towards
The Presentation Of Acute Headache
1. To diagnose & treat “Critical Life Threatening“
...
Examples ?
What Do We Need To Catch In E.R ?
Rapid Initial Assessment
- Stabilization Of Airway , Breathing , Circulation.
- Make sure the patient is Vitally Stable be...
Rapid Initial Assessment
- Get the Short version of the story , Look at
vitals , Ask about allergies .
- Tell the patient ...
Initial Assessment
- When you're ready for the main assessment :
1- Do a full assessment of Pain (in this case Headache).
...
Pain Assessment Items
• Character & Pattern.
• Onset & Time Needed To Reach Maximum Intensity.
• Duration & Frequency.
• L...
History
• Character & Pattern :
- First severe headache ?
- Worst headache ever ?
- Steady worsening over several days ?
-...
History
• Character & Pattern :
• The “Thunder clap” or “Lightning strike” are Real
Phenomena and are sensitive of SAH but...
History
• Onset :
• The Rapidity & Rate of onset of pain may have
significance.
• It suggests a Primary Vascular Origin.
•...
History
• Onset :
• Sudden-onset headache, especially if it begins
during exertion (including coughing, defecation,
etc.),...
History
• Duration & Frequency:
• Continuous vs. Intermittent ?
• Favoring times , seasons , associations ?
• It helps but...
History
• Location & Radiation :
• Mostly , nonspecific and should not be relied on for
diagnosis.
• An occipitonuchal loc...
History
• Location & Radiation :
• The Unilateral Headaches is more suggestive of Migraine or a Localized
inflammatory pro...
History
• Severity / Intensity / Impact :
• Difficult to quantify objectively.
• Almost all patients who present to the ED...
History
• Relieving/ Aggravation Factors :
• Patients whose headaches rapidly improve when they are
removed from their env...
History
• Relieving/ Aggravation Factors :
• Change of Postures , Location ?
• Maneuvers : Valsalva , Banding , Ice ?
• Do...
History
• Relation To Actions Or Events :
• Headache with exertion have a relationship to vascular
bleeding, but again, th...
History
• Response To Treatment :
• What & how much did you take ? How many times ?
• What is the usual response ?
• Usual...
History
• Associated Symptoms :
- General : like nausea and vomiting , etc. (Completely Nonspecific)
- Red Flags :
- Synco...
History
• Previous Experience & Comparison :
• Although helpful, does not rule out current serious problems.
• CAN A PATIE...
History
• Family History :
• Migraine headaches occur more commonly in patients with a
family history of migraines ..
• Wh...
History
• Medical Hx & Co-Morbidities :
- Malignancies: Primary vs. Secondary ? Invasion to Brain tissue or Vessels ?
- HI...
History
• Miscellaneous :
- Medications : (e.g., nitroglycerin, analgesics used long term,
monoamine oxidase inhibitors, o...
History
• Systemic Inquiry :
- Asking about symptoms of involved systems often completes
your history and makes things muc...
Finally
• Expectations :
- What does the patient expect this pain to be due to ?
- What are his/her fears or concerns ?
- ...
Risk Factors Associated with
Potentially Catastrophic Illness
Physical Examination
• General Appearance
• Vitals
• Pain
• Neuro Exam
• Head & Neck Exam
• Eye Exam
• ENT Exam
Pivotal Findings On Physical Exam
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
• Definition: Bleeding in the subarachnoid space
• Spontaneously, usually from a
ruptured cerebral...
Subarachnoid Hemorrhage
- Historical Red Flags :
- Rapid reach to maximum pain intensity “ minutes to seconds ‘.
- First o...
Subarachnoid Hemorrhage
- Physical Exam Red Flags :
- Altered Mental Status.
- High Blood Pressure.
- Meningeal Signs.
- D...
Subarachnoid Hemorrhage
Subhyaloid Hemorrhage
Subarachnoid Hemorrhage
- At the time of presentation, almost half of patients with subarachnoid
hemorrhage have Normal fi...
Meningitis / Encephalitis / Abscess
Meningitis / Encephalitis / Abscess
- History Red Flags :
- Photophobia.
- Fever , Nausea & Vomiting.
- Recent or Current ...
Meningitis / Encephalitis / Abscess
- Physical Exam Red Flags :
- Toxic Appearance
- Febrile
- Nuchal Rigidity
- Stretchin...
Meningitis / Encephalitis / Abscess
Q : What Should We
Do , CT ? LP ? ABX ?
Which One Goes
First ?
Temporal Arteritis
Temporal Arteritis
• It’s a type of inflammation to the arteries ,
highly associated with vacuities and
connective tissue ...
Temporal Arteritis
- History Red Flags :
- Age Over 50.
- Highly localized.
- Decreased vision.
- Collagen / Vacuities dis...
Temporal Arteritis
- Physical Exam Red Flags :
- None pulsatile.
- Tender at Site.
- Diminished pulses.
- Bruits.
- Diplop...
Temporal Arteritis
If ESR Is Low , Likelihood Ratio Of Dx Is Very Low
Temporal Arteritis
So Why So Serious ? 
The most serious complication is loss of vision,
usually due to ischemic optic ne...
Cerebral Venous Thrombosis
Cerebral Venous Thrombosis
• Definition : presence of thrombosis in the dural venous
sinuses, which drain blood from the b...
Cerebral Venous Thrombosis
- History Red Flags :
- Thunderclap , Lightning Strike.
- N & V.
- Focal Weakness.
- Altered Le...
Cerebral Venous Thrombosis
- Physical Exam Red Flags :
- Focal Weakness.
- Signs Of Raised ICP.
- Cushing Reflex.
- Looks ...
The Other Intercerebral Bleeds
Intercerebral Bleeds
Intercerebral Bleeds
• Risk Factors For Subdural ( Weak Veins ) :
• A low threshold for initiating investigation is approp...
Carbon Monoxide Poisoning
Carbon Monoxide Poisoning
Carbon Monoxide Poisoning
• History Red Flags :
• Lightheadedness.
• Confusion.
• Vertigo.
• Flu-like symptoms.
• Enclosed...
Carbon Monoxide Poisoning
• Physical Exam Red Flags :
- Looks Like Flu.
- Low Grade Fever.
- Flushed Mucous Membrane.
- Ta...
Cervical Artery Dissection
Cervical Artery Dissection
• Dissection may be spontaneous or the result of trauma and
generally occurs in younger patient...
Stroke
Stroke
• Big Topic & Wont Be Covered In This Lecture
• Headache , N&V , Slurred Speech , Focal
Weakness , Seizures , Distu...
Brain Mass
Brain Mass
• Up to 70% of patients with brain tumors complain of headache at the
time of diagnosis, and only about 8% have...
Acute Angle-Closure Glaucoma
Acute Angle-Closure Glaucoma
• Increased intra ocular pressure causing optic nerve
damaged in a characteristic pattern.
• ...
Benign Intracranial Hypertension
• Formerly called pseudotumor cerebri , Now called
Idiopathic , a rare entity.
• Classica...
Special Considerations
• Women :
- Migraine headaches are more common in women
and are influenced by hormonal factors.
- M...
Special Considerations
• Pregnant Women :
- Preeclampsia should be considered.
- Pregnancy improves migraine symptoms in 6...
Finally , Primary Headaches
Finally , Primary Headaches
Significant Symptoms , Findings & Dx
Lets Not Forget These Causes
Diagnosis
• How do you reach a diagnosis in headache ?
• What is the most useful tool ? Labs ? Radio ?
• Who Gets To Be CT...
Diagnosis
• History And Physical Exam :
- Is The Most Useful Tool in diagnosing headache
or initiating a correct diagnosti...
Diagnosis
• CT :
• Diagnostic investigation usually begins with a Noncontrast CT scan.
• usually adequately excludes criti...
Diagnosis
• CT :
• The single largest consistent mistake made by emergency
physicians in the workup of the headache patien...
Diagnosis
• Lumbar Puncture :
• Lumbar puncture (LP) is required in cases such as suspected meningitis or
suspected subara...
Diagnosis
• MRI :
• The cost and restricted availability of MRI limit its utility in the
emergency investigation of headac...
ACEP Guidelines With Management
And Disposition Of Acute None
Traumatic Headache In Adults
• 1. Does a response to therapy...
• 2. Which patients with headache require neuroimaging in the ED?
• Level A recommendations. None specified.
• Level B rec...
• 3. Does lumbar puncture need to be routinely performed on ED
patients being worked up for nontraumatic subarachnoid
hemo...
• 4. In which adult patients with a complaint of
headache can a lumbar puncture be safely
performed without a neuroimaging...
• 5. Is there a need for further emergent diagnostic
imaging in the patient with sudden-onset, severe
headache who has neg...
Do All Of Them Have Migraine Or
Need CT Imaging ?
Do All Of Them Have Migraine Or
Need CT Imaging ?
• It was a systematic review done from MEDLINE from 1966 – 2005
• All 4 ...
Diagnostic Adjuncts For Assessment
Of Headache
Treatment
• Few studies are available to guide empiric management of
undifferentiated headache in the ED; treatment remain...
Treatment
• A Pretreatment with 12.5 mg of diphenhydramine or
1 mg of benztropine is suggested to avoid akathisia.
• Other...
Abortive Treatments Of Headache
Disposition
• Remember What Evidence And Practice Said ?
• Generally Speaking A Safe Risk Stratification
Made Of “ All Cle...
“Warning Signals”
• (1) sudden onset of headache.
• (2) “the worst headache ever”.
• (3) decreased or altered mental statu...
“All Clear Signals”
• (1) previous identical headaches.
• (2) normal alertness and cognition by both examination
and histo...
Don’t Be Confused
• Although The Following Guide Might Look
Confusing At First Sight ..
• It Would Be A Very Safe Way To G...
References
• Rosen
• Tentinalli
• ACEP
• JAMA
• UpToDate
The End
Any Questions ?
Emergency Medicine Approach To Headache
Emergency Medicine Approach To Headache
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Emergency Medicine Approach To Headache

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Emergency Medicine Approach To Headache

  1. 1. Dr. Nawaf Al-Amri M.D Senior Resident Saudi Board Of Emergency Medicine
  2. 2. We’re Going To Cover The Following - Basics Of Headache : The Anatomy & Physiology Of The Pathology - Headache Epidemiology & Toll Of Healthcare Emergency - Emergency Medicine Attitude Towards Acute Headache - Initial Assessment , Investigations & Management - Differential Diagnosis - Risk Stratification - Disposition
  3. 3. What Is Headache ? • Headache: is pain anywhere in the region of the head or neck. • Pain in the head and neck may easily overlap. • So they should be thought of ( as a unit ) when considering complaints of headache.
  4. 4. Pathophysiology Of Headache • Brain tissue doesn’t feel pain i.e no pain receptors in the actual tissue . • Rather, the pain is caused by disturbance of the pain-sensitive structures around or within the brain that have ( Nociceptors ) , Like :
  5. 5. Pathophysiology Of Headache • Cranium (Periosteum Of The Skull). • Meninges. • Nerves. • Vessels. • Eyes. • Ears. • Sinuses. • Muscles. • Subcutaneous Tissues. • Mucous Membranes.
  6. 6. Pathophysiology Of Headache • The ability of the patient to specifically localize head pain is often poor if the area involved is not superficial or of a certain pathology • A specific inflammation in a specific structure (e.g., periapical abscess, sinusitis, tic douloureux , temporal arteritis ) is much easier to localize.
  7. 7. Pathophysiology Of Headache • Much of the pain associated with headache, particularly with vascular headache and migraines, is mediated through the fifth cranial nerve. • It proceed back to the nucleus and then be radiated through various branches of the fifth cranial nerve to areas not directly involved.
  8. 8. Pathophysiology Of Headache • The Nociceptors may be stimulated by : • Inflammation Or Infection. • Stretching , Tension , Dilatation Or Pressure. • Trauma. • Direct Invasion. • Irritation Or Stress.
  9. 9. Pathophysiology Of Headache • It has been suggested that the level of endorphins may have a great impact on the sensation of headache. • Higher levels of endorphins are associated with lower incidence of headaches on a chronic term , vice versa is also correct .
  10. 10. Pathophysiology Of Headache * Two Suggested Theories For The Pathophysiology Of Headaches / Migraines : • Old : The Vascular Theory : - Intracranial vasoconstriction is responsible for the aura of the migraine. - Headache is results from the subsequent rebound dilatation which leads to the activation of the perivascular nociceptive nerves.
  11. 11. Pathophysiology Of Headache - New : The Neurological Theory : - Headaches/ Migraines are triggered by a complex series of neural and vascular events , due to Neuronal hyper-excitability in the cerebral cortex, especially in the occipital cortex.
  12. 12. Headache Epidemiology • Headache as a primary complaint represents between 3 and 5% of all (ED) visits. • More common in Females than Males (3:1). • The majority of patients who have the primary complaint of headache , Do not have a serious medical cause for the problem.
  13. 13. Headache Epidemiology • Less than 1% of patients who present to the ED with headache have Life-Threatening secondary causes.
  14. 14. Headache Epidemiology • These percentages can create a False sense of security. • The most commonly encountered life threatening cause of severe sudden headache is Subarachnoid hemorrhage (SAH) , it also is the most salvageable at early stages !!
  15. 15. Headache Epidemiology • It is estimated that between 25 and 50% of SAH are missed on the first presentation. • It Is noted that Most SAH are missed are of low grade “I’’ ,which sadly has the best prognosis !
  16. 16. Headache Epidemiology - Most common type of Primary Headache in ED is TENSION > MIGRAINE > CLUSTER. - Factors predisposing to Migraines : - Family history of migraines. - Females. - Females who are experiencing hormonal changes Birth control pills or Hormone replacement therapy.
  17. 17. Emergency Medicine Attitude Towards The Presentation Of Acute Headache 1. To diagnose & treat “Critical Life Threatening“ secondary headache causes. 2. To diagnose and treat “Benign & Reversible“ secondary headache causes. 3. To effectively treat “Primary Headaches“. 4. To provide “Appropriate disposition & follow-up“.
  18. 18. Examples ?
  19. 19. What Do We Need To Catch In E.R ?
  20. 20. Rapid Initial Assessment - Stabilization Of Airway , Breathing , Circulation. - Make sure the patient is Vitally Stable before starting to take history & do physical examination. - If you help from a Senior Resident or An Attending don’t be Shy , Afraid or Hesitant .. we’ve all been there , Patient’s safety is what matters .
  21. 21. Rapid Initial Assessment - Get the Short version of the story , Look at vitals , Ask about allergies . - Tell the patient that he/she is going to feel much better. - Provide the Proper investigations , treatment & disposition.
  22. 22. Initial Assessment - When you're ready for the main assessment : 1- Do a full assessment of Pain (in this case Headache). 2- Take a full & proper History. 3- Do a full & proper Physical Examination. 4- Formulate a Differential Diagnosis. 5- Investigate & Treat the Presentation & Causatives.
  23. 23. Pain Assessment Items • Character & Pattern. • Onset & Time Needed To Reach Maximum Intensity. • Duration & Frequency. • Location & Radiation. • Severity / Intensity / Impact. • Relieving/ Aggravation Factors. • Relation To Actions Or Events. • Response To Treatment. • Associated Symptoms. • Previous Experience / Comparison. • Medical , Surgical , Occupational , Exposure & Family Hx. • Systemic Inquiry Of The System Involved. • Ask About RED FLAGS. • Expectations ?
  24. 24. History • Character & Pattern : - First severe headache ? - Worst headache ever ? - Steady worsening over several days ? - Significant differences from prior headaches in terms of duration, severity, or associated symptoms ? - Throbbing , Stabbing , Dull , Sharp , Electrical , Thunder Clap ?
  25. 25. History • Character & Pattern : • The “Thunder clap” or “Lightning strike” are Real Phenomena and are sensitive of SAH but not specific. • Having Another Character of pain or Improvement of it at the time of evaluation doesn’t rule out the diagnosis.
  26. 26. History • Onset : • The Rapidity & Rate of onset of pain may have significance. • It suggests a Primary Vascular Origin. • Most studies dealing with SAH report that patients moved from the Pain-free state to severe pain within seconds to minutes !!
  27. 27. History • Onset : • Sudden-onset headache, especially if it begins during exertion (including coughing, defecation, etc.), is an independent predictor of intracranial pathology, and up to 25% of such headaches are caused by Subarachnoid hemorrhage.
  28. 28. History • Duration & Frequency: • Continuous vs. Intermittent ? • Favoring times , seasons , associations ? • It helps but mostly in Primary Headaches ..
  29. 29. History • Location & Radiation : • Mostly , nonspecific and should not be relied on for diagnosis. • An occipitonuchal location of headache is an Independent predictor of intracranial pathology & is the Most common location for SAH.
  30. 30. History • Location & Radiation : • The Unilateral Headaches is more suggestive of Migraine or a Localized inflammatory process in the skull (e.g., sinus) or soft tissue. • The Occipital Headaches are associated with hypertension (Myth?) • Diseases like Temporal arteritis, temporomandibular joint disease, dental infections, and sinus infections frequently have a Highly Localized areas. • Diseases like Meningitis, Encephalitis, SAH, & Even Severe Migraines , although intense in nature, are usually More Diffuse in their localization.
  31. 31. History • Severity / Intensity / Impact : • Difficult to quantify objectively. • Almost all patients who present to the ED consider their headache to be “Severe”. • Use of a pain scale of 1 to 10 may help in Monitoring Response & Affectivity Of Therapy.
  32. 32. History • Relieving/ Aggravation Factors : • Patients whose headaches rapidly improve when they are removed from their environment may have CO Poisoning !! • Headaches on awakening are typically described with brain tumors. (Really ?) • Most other severe causes of headache like SAH, Intracranial infections, dental infections , etc. don’t tend to improve before presenting to ER where therapy is given .
  33. 33. History • Relieving/ Aggravation Factors : • Change of Postures , Location ? • Maneuvers : Valsalva , Banding , Ice ? • Does it really matter ? Why ?
  34. 34. History • Relation To Actions Or Events : • Headache with exertion have a relationship to vascular bleeding, but again, there is enough variation to make assignment to any specific cause highly variable. • The syndrome of coital or postcoital headache is well known, but coitus is also a common time of onset for SAH. • When you here (“ I was just getting up out of the chair to answer the doorbell , I felt like something poped in my head and felt dizzy ”) BE CONCERNED , This has a high LHR of SAH !!
  35. 35. History • Response To Treatment : • What & how much did you take ? How many times ? • What is the usual response ? • Usually guides you to choose proper treatment . • DOES NOT HELP YOU IN YOUR DX MUCH , AND IS CERTINLLY NOT A WAY TO DIFF BETWEEN LIFE THREATNING AND NOT ..
  36. 36. History • Associated Symptoms : - General : like nausea and vomiting , etc. (Completely Nonspecific) - Red Flags : - Syncope - Altered level of consciousness or confusion. - Neck pain or stiffness. - Persistent visual disturbance. - Fever. - Seizure.
  37. 37. History • Previous Experience & Comparison : • Although helpful, does not rule out current serious problems. • CAN A PATIENT WHO IS ALREADY KNOWN TO HAVE MIGRAINES DEVELOP SAH , MENIGITIS , BRAIN TUMOR , STROKE ? • Is it the same or is it different ? • Know that the patient has had a workup properly or not ! • Previous ED visits, computed tomography (CT) magnetic resonance imaging, and other forms of testing should be inquired about.
  38. 38. History • Family History : • Migraine headaches occur more commonly in patients with a family history of migraines .. • What has that particular same association ? • SAH is Up to four times higher in first- and second-degree relatives of individuals with subarachnoid hemorrhage than in the general population .
  39. 39. History • Medical Hx & Co-Morbidities : - Malignancies: Primary vs. Secondary ? Invasion to Brain tissue or Vessels ? - HIV/AIDS: Toxoplasmosis, Cryptococcus , Meningitis , TB , Abscess ? - Coagulopathies: Induced or Not >> all kinds of bleeds . - Hypertension: is it the mythical HTN induced or is it an aneurism that popped ? - Diabetes: all of the above ? - Migraines: What kind of therapy ? Were they really diagnosed ? - Previous Bleeds: High Reoccurrence !!
  40. 40. History • Miscellaneous : - Medications : (e.g., nitroglycerin, analgesics used long term, monoamine oxidase inhibitors, or anticoagulants) . - History of Trauma : Fractures , contusions , subdurals , epidurals , intercerebral , SAH , axonal injury , concussion ? - Toxic Exposures : (e.g., carbon monoxide) may be important associations with headache. - Weather : Any relation ? Hot Vs Cold ?
  41. 41. History • Systemic Inquiry : - Asking about symptoms of involved systems often completes your history and makes things much more clear . - Neuro / ENT / Ophtha / Musculoskeletal .. Etc.
  42. 42. Finally • Expectations : - What does the patient expect this pain to be due to ? - What are his/her fears or concerns ? - Will the pain go away ? Is it going to be better ? - What can the ED investigations yield ? - What will this end up with ?
  43. 43. Risk Factors Associated with Potentially Catastrophic Illness
  44. 44. Physical Examination • General Appearance • Vitals • Pain • Neuro Exam • Head & Neck Exam • Eye Exam • ENT Exam
  45. 45. Pivotal Findings On Physical Exam
  46. 46. Subarachnoid Hemorrhage
  47. 47. Subarachnoid Hemorrhage • Definition: Bleeding in the subarachnoid space • Spontaneously, usually from a ruptured cerebral aneurysm. • May result from Trauma.
  48. 48. Subarachnoid Hemorrhage - Historical Red Flags : - Rapid reach to maximum pain intensity “ minutes to seconds ‘. - First or worst headache in life. - Thunder clap or lightning strike headache. - Syncope or Presyncope . - Seizures. - Altered Mental Status or Confusion ( Bad Prognostic Sign ). - With Exertion ( Sudden Or Prolonged ). - Occipitonuchal Headache ( Meningeal Irritation ) Usually Not Benign Acutely. - Prior Hx Of SAH. - Family Hx 1st Or 2nd Degree Relatives. - Medications Like Anticoagulants , NSAIDs , Aspirin , Sympathomimetic. - Connective Tissue Disease. - Polycystic Kidney Disease. - Bleeding Diathesis. - Uncontrolled Hypertension. - Young And Middle Age ?
  49. 49. Subarachnoid Hemorrhage - Physical Exam Red Flags : - Altered Mental Status. - High Blood Pressure. - Meningeal Signs. - Decreased Pulse. - Subhyaloid Hemorrhage ( GOOD LUCK WITH THAT ONE ) - Low Grade Fever. - Signs Of Raised ICP. - Cushing Reflex ?
  50. 50. Subarachnoid Hemorrhage Subhyaloid Hemorrhage
  51. 51. Subarachnoid Hemorrhage - At the time of presentation, almost half of patients with subarachnoid hemorrhage have Normal findings on neurologic examination, including normal vital signs and level of consciousness. - The headache of subarachnoid hemorrhage is most commonly severe and of sudden onset, but it also may be more subtle. - Investigation of suspected subarachnoid hemorrhage usually begins with a noncontrast CT scan of the head. - No study has convincingly demonstrated that CT scanning alone can exclude subarachnoid hemorrhage, even within 12 hours of onset of symptoms. - LP to be necessary after negative findings on CT scan if subarachnoid hemorrhage is suspected. - The gold standard for the diagnosis of subarachnoid hemorrhage is the presence of xanthochromia in the cerebrospinal fluid (CSF) supernatant , Traumatic LP MEANS ZERO RBC in Tube 3 or 4 !!
  52. 52. Meningitis / Encephalitis / Abscess
  53. 53. Meningitis / Encephalitis / Abscess - History Red Flags : - Photophobia. - Fever , Nausea & Vomiting. - Recent or Current Infection e.g. ENT Infection. - Gradual increase in intensity. - Altered mental status Or Confusion. - Seizures. - Neck pain or stiffness. - Irritability. - Diffuse Distribution. - Recent facial or dental or ENT surgery. - Immunocompromised . - Exposure to ill individuals. - Impacted conditions or travel. - Extremes of age.
  54. 54. Meningitis / Encephalitis / Abscess - Physical Exam Red Flags : - Toxic Appearance - Febrile - Nuchal Rigidity - Stretching & Irritation Exams ? Sens Or Spec ? LHR ?
  55. 55. Meningitis / Encephalitis / Abscess Q : What Should We Do , CT ? LP ? ABX ? Which One Goes First ?
  56. 56. Temporal Arteritis
  57. 57. Temporal Arteritis • It’s a type of inflammation to the arteries , highly associated with vacuities and connective tissue diseases • Temporal Arteritis is just a subdivision of a larger definition of a disease .
  58. 58. Temporal Arteritis - History Red Flags : - Age Over 50. - Highly localized. - Decreased vision. - Collagen / Vacuities disease. - Temporal , Forehead , Periorbital Or Retro-orbital. - Associated with Mastication. - Females > Males ( 4:1 ). - Chronic illness. - Jaw claudication. - Polymyalgia Rheumatica. - Tongue claudication. - Fever
  59. 59. Temporal Arteritis - Physical Exam Red Flags : - None pulsatile. - Tender at Site. - Diminished pulses. - Bruits. - Diplopia. - True Tongue & Jaw Claudication. - Decrease of visual acuity. - Loss of Visual field.
  60. 60. Temporal Arteritis If ESR Is Low , Likelihood Ratio Of Dx Is Very Low
  61. 61. Temporal Arteritis So Why So Serious ?  The most serious complication is loss of vision, usually due to ischemic optic neuritis.
  62. 62. Cerebral Venous Thrombosis
  63. 63. Cerebral Venous Thrombosis • Definition : presence of thrombosis in the dural venous sinuses, which drain blood from the brain. • Results from hypercoagulable states. • Risk factors : • Oral contraceptives. • Postpartum state. • Postoperative state. • Diagnosis is confirmed by MRV .
  64. 64. Cerebral Venous Thrombosis - History Red Flags : - Thunderclap , Lightning Strike. - N & V. - Focal Weakness. - Altered Level Of Consciousness Or Confusion. - Seizures. - Not So Specific ? Right ?
  65. 65. Cerebral Venous Thrombosis - Physical Exam Red Flags : - Focal Weakness. - Signs Of Raised ICP. - Cushing Reflex. - Looks Like A Stroke Or Bleed ?
  66. 66. The Other Intercerebral Bleeds
  67. 67. Intercerebral Bleeds
  68. 68. Intercerebral Bleeds • Risk Factors For Subdural ( Weak Veins ) : • A low threshold for initiating investigation is appropriate for high-risk patients, including : • Patients taking anticoagulants. • Patients with chronic alcoholic abuse. • The elderly, in whom there may be no clear history of trauma. • If a noncontrast CT Normal >> doesn’t mean its not there
  69. 69. Carbon Monoxide Poisoning
  70. 70. Carbon Monoxide Poisoning
  71. 71. Carbon Monoxide Poisoning • History Red Flags : • Lightheadedness. • Confusion. • Vertigo. • Flu-like symptoms. • Enclosed spaces with a source. • Multiple family or residents with same symptoms. • Pattern of recurrence. • Winter time.
  72. 72. Carbon Monoxide Poisoning • Physical Exam Red Flags : - Looks Like Flu. - Low Grade Fever. - Flushed Mucous Membrane. - Tachycardia. - Hypotension. - Arrhythmia. - Delirium. - Hallucinations. - Dizziness. - Unsteady gait. - Confusion. - Seizures. - Respiratory arrest.
  73. 73. Cervical Artery Dissection
  74. 74. Cervical Artery Dissection • Dissection may be spontaneous or the result of trauma and generally occurs in younger patients (median age, 40 years). • Internal Carotid Artery Dissection may be suspected in a patient with Unilateral Anterior Neck Pain or Headache, usually around the eye or frontal area. • Most patients present with or eventually develop Neurologic Signs e.g : TIA, stroke, Horner syndrome, transient monocular blindness, or cranial nerve palsies. • Vertebral Artery Dissection typically presents with marked Occipital or Posterior Neck Pain associated with signs of a brainstem TIA or Stroke.
  75. 75. Stroke
  76. 76. Stroke • Big Topic & Wont Be Covered In This Lecture • Headache , N&V , Slurred Speech , Focal Weakness , Seizures , Disturbed Gait .. Etc. • Remember ABCD , And Time = Brain
  77. 77. Brain Mass
  78. 78. Brain Mass • Up to 70% of patients with brain tumors complain of headache at the time of diagnosis, and only about 8% have abnormal findings on neurologic examination. • The headache may be unilateral or bilateral, intermittent or continuous ( not sensitive or specific ) • The classic headache of brain tumors (worse in the morning, associated with position and nausea and vomiting) occurs in only a few , hence the word CLASSIC • Its Not Always a Tumor , Might Be An Abscess , A Cyst Or a Big Aneurism!
  79. 79. Acute Angle-Closure Glaucoma
  80. 80. Acute Angle-Closure Glaucoma • Increased intra ocular pressure causing optic nerve damaged in a characteristic pattern. • This can permanently damage vision in the affected eye(s) and lead to blindness if left untreated. • Alarming Hx : Sudden Headache , From Dark to Light , Visual Disturbance. • Alarming Ex : Sluggish Reaction , Mid Dilated , Hazy Cornea , Redness , Papilledema , Raised IOP.
  81. 81. Benign Intracranial Hypertension • Formerly called pseudotumor cerebri , Now called Idiopathic , a rare entity. • Classically : • Young • Obese • Female • Chronic headache. • On OCP • Not So Benign If It Can Cause … Loss Of Vision
  82. 82. Special Considerations • Women : - Migraine headaches are more common in women and are influenced by hormonal factors. - Menarche, menstruation, oral contraceptive use, pregnancy, and menopause all may affect migraine. - Higher estrogen levels generally are associated with improved symptoms , Like : PREGNANCY !
  83. 83. Special Considerations • Pregnant Women : - Preeclampsia should be considered. - Pregnancy improves migraine symptoms in 60% to 70% of patients. - Venous sinus thrombosis should be considered as a cause of headache during pregnancy and the postpartum state.
  84. 84. Finally , Primary Headaches
  85. 85. Finally , Primary Headaches
  86. 86. Significant Symptoms , Findings & Dx
  87. 87. Lets Not Forget These Causes
  88. 88. Diagnosis • How do you reach a diagnosis in headache ? • What is the most useful tool ? Labs ? Radio ? • Who Gets To Be CT-ed , And Who Doesn’t ? Any Bases ? • Who Goes Out ? Who Goes In ?
  89. 89. Diagnosis • History And Physical Exam : - Is The Most Useful Tool in diagnosing headache or initiating a correct diagnostic process. • Labs : - No such thing is a basic workup. - Order things you can correlate to. - There are very few Lab workup that might help.
  90. 90. Diagnosis • CT : • Diagnostic investigation usually begins with a Noncontrast CT scan. • usually adequately excludes critical lesions or mass effects requiring emergent interventions. • In particular, noncontrast CT is the best neuroimaging test for diagnosing an acute subarachnoid hemorrhage, although negative findings on a CT scan alone cannot exclude subarachnoid hemorrhage. • When there is strong suspicion of small lesions likely to be missed without the use of contrast (e.g., in a patient with acquired immunodeficiency syndrome suspected of having cerebral toxoplasmosis or a small brain mass), then a CT with IV contrast material or MRI may be needed. • In patients with subarachnoid hemorrhage confirmed on CT, use of multidetector CT angiography to detect and characterize aneurysms may help in deciding whether to coil or to clip an aneurysm.
  91. 91. Diagnosis • CT : • The single largest consistent mistake made by emergency physicians in the workup of the headache patient is believing a single CT scan clears the patient of the possibility of SAH or other serious intracranial disease. • The CT scan can miss 6 to 8% of patients with SAH, especially in patients with minor (grade I) SAH, who are most treatable. • The sensitivity of CT for identifying SAH is reduced by nearly 10% for symptom onset greater than 12 hours and by almost 20% at 3 to 5 days.
  92. 92. Diagnosis • Lumbar Puncture : • Lumbar puncture (LP) is required in cases such as suspected meningitis or suspected subarachnoid hemorrhage when CT scan findings are normal. • LP should be preceded by CT scan if raised intracranial pressure is suspected to determine if contraindications to LP exist. • Elevated intracranial pressure can be excluded by a combination of the absence of papilledema, normal level of consciousness, and normal findings on neurologic examination. • Absence of papilledema by itself is unreliable, because papilledema may not be apparent with rapidly developing intracranial pressure, or even with high levels of pressure. • If all conditions are met and were CLEAR , then a CT scan is not required prior to LP, especially if the CT procedure is likely to be delayed.
  93. 93. Diagnosis • MRI : • The cost and restricted availability of MRI limit its utility in the emergency investigation of headache. • MRI is more sensitive than CT in evaluating brain injuries, such as diffuse axonal injuries, small parenchymal contusions, isodense subdural hemorrhages, and most tumors. • In acute subarachnoid hemorrhage, however, and as of this writing, MRI is no more sensitive than CT in the first few days following a bleed. • CT and LP are adequate for the large majority of ED headache patients requiring emergent investigation.
  94. 94. ACEP Guidelines With Management And Disposition Of Acute None Traumatic Headache In Adults • 1. Does a response to therapy predict the etiology of an acute headache? • Level A recommendations. None specified. • Level B recommendations. None specified. • Level C recommendations : Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.
  95. 95. • 2. Which patients with headache require neuroimaging in the ED? • Level A recommendations. None specified. • Level B recommendations : • Patients presenting to the ED with headache and new abnormal findings in a neurologic examination (eg, focal deficit, altered mental status, altered cognitive function) should undergo emergent noncontrast head CT. • Patients presenting with new sudden-onset severe headache should undergo an emergent head CT. • HIV-positive patients with a new type of headache should be considered for an emergent neuroimaging study. • Level C recommendations: Patients who are older than 50 years and presenting with new type of headache but with a normal neurologic examination should be considered for an urgent neuroimaging study.
  96. 96. • 3. Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain CT scans are interpreted as normal? • Level A recommendations. None specified. • Level B recommendations: In patients presenting to the ED with sudden-onset, severe headache and a negative noncontrast head CT scan result, lumbar puncture should be performed to rule out subarachnoid hemorrhage. • Level C recommendations. None specified
  97. 97. • 4. In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study? • Level A recommendations. None specified. • Level B recommendations. None specified. • Level C recommendations: Adult patients with headache and exhibiting signs of increased intracranial pressure (eg, papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging study before having a lumbar puncture.
  98. 98. • 5. Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumbar puncture? • Level A recommendations. None specified. • Level B recommendations: Patients with a sudden-onset, severe headache who have negative findings on a head CT, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up recommended. • Level C recommendations. None specified.
  99. 99. Do All Of Them Have Migraine Or Need CT Imaging ?
  100. 100. Do All Of Them Have Migraine Or Need CT Imaging ? • It was a systematic review done from MEDLINE from 1966 – 2005 • All 4 of the migraine studies illustrated high sensitivity and specificity if 3 or 4 criteria were met. • The best predictors can be summarized by the mnemonic : POUNDing • (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling). • If 4 of the 5 criteria are met, the likelihood ratio (LR) for definite or possible migraine is 24 (95% confidence interval [CI], 1.5-388). • if 3 are met, the LR is 3.5 (95% CI, 1.3-9.2). • if 2 or fewer are met, the LR is 0.41 (95% CI, 0.32-0.52).
  101. 101. Diagnostic Adjuncts For Assessment Of Headache
  102. 102. Treatment • Few studies are available to guide empiric management of undifferentiated headache in the ED; treatment remains symptom-based and largely nonspecific. • Use Paracetamol 1 g I.V • Use Ketrolac 30 mg I.V • Use Prochlorperazine10 mg I.V • Or Chlorpromazine0.1 mg/kg I.V
  103. 103. Treatment • A Pretreatment with 12.5 mg of diphenhydramine or 1 mg of benztropine is suggested to avoid akathisia. • Other medications used to treat undifferentiated headache in the ED include sumatriptan , olanzapine , metoclopramide and droperidol. • Although Not Encouraged , If Opioids Are Needed Then They Have to Be Given Like Morphine 0.1 mg/kg.
  104. 104. Abortive Treatments Of Headache
  105. 105. Disposition • Remember What Evidence And Practice Said ? • Generally Speaking A Safe Risk Stratification Made Of “ All Clear “ Or “ Red Flags “ Can Help • At The End , Your Not Supposed To Diagnose Every Headache That Comes , Concentrate On The Lethal 1 %
  106. 106. “Warning Signals” • (1) sudden onset of headache. • (2) “the worst headache ever”. • (3) decreased or altered mental status . • (4) true meningismus. • (5) unexplained fever or bradycardia. • (6) focal neurologic deficits on examination. • (7) symptoms refractory to treatment or worsening under observation. • (8) new onset of headache with exertion. • (9) history of HIV. • (10) Abnormal Vital Signs.
  107. 107. “All Clear Signals” • (1) previous identical headaches. • (2) normal alertness and cognition by both examination and history of the event. • (3) normal examination of the neck showing no meningismus. • (4) normal vital signs. • (5) normal or nonfocal neurologic examination. • (6) improvement under observation or with treatment.
  108. 108. Don’t Be Confused • Although The Following Guide Might Look Confusing At First Sight .. • It Would Be A Very Safe Way To Go By • By Time And Practice , This Will Be Imprinted In Your Brain With Complete Ease …..
  109. 109. References • Rosen • Tentinalli • ACEP • JAMA • UpToDate
  110. 110. The End Any Questions ?

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