Approach to acute onset headache

1. Approach to acute headache
Dr Vaishal Shah
SR Neurology
GMC Kota

2. Introduction
• M/C medical complaint in neuro OPD.
• Rule out serious underlying pathology and look for other secondary
causes of headache.
• For that, danger signs should keep in mind.
• Determine the type of primary headache using the patient history as
the primary diagnostic tool.

3. Introduction
• 90% of all primary headache fall among one of these 3 categories –
Migraine, TTH, cluster headache.
• Episodic TTH is the commonest among them.
• Overlapping symptoms between migraine & TTH and migraine and
some secondary headache like sinus disease can occur.

4. Introduction
• Brazilian primary care study – 561 patients
• 55.6% - primary headache
• 39% - systemic disorder ( M/C fever, hypertension,sinusitis )
• 5% - neurological disorder ( M/C posttraumatic, cervical spine
disease, SOL, IIH )

5. Low risk features
• Age < 50 years
• Features typical of primary headaches
• History of similar headache
• No abnormal neurologic findings
• No concerning change in usual headache pattern
• No high-risk comorbid conditions
• No new or concerning findings on history or examination

7. High risk features

9. Evaluation of High risk features
• Sudden onset "thunderclap" headache

10. Evaluation of High risk features
• Approximately 8 % of patients with a thunderclap headache have
SAH.
• CT f/b LP
• Because the consequences of missing SAH are potentially dire, most
guidelines state that an LP should be performed in all patients with
suspected SAH in whom the CT is normal.

11. Evaluation of High risk features
• New headache with focal neurologic deficit or papilledema
• ICSOL ( primary or metastatic neoplasm, abscess, hematoma )
• communicating or obstructive hydrocephalus
• cerebral edema from ischemia or infarction (ie, stroke, CVT)
• CT with contrast.

12. Evaluation of High risk features
• New headache with altered mental status with or without nuchal
rigidity
• Meningitis, encephalitis, CVT
• CT brain with contrast with venogram.

13. Evaluation of High risk features
• An acute headache accompanied by eye pain or diminished vision,
typically unilateral, suggests acute angle-closure glaucoma.
• Examination typically reveals a red eye with ciliary flush and no
discharge, a pupil fixed in mid-dilation, and a cornea that is
edematous or "steamy" appearing

15. Evaluation of High risk features
• New headache with neck pain and/or Horner syndrome
• Headache that radiates into the neck may be the result of carotid or
vertebral artery dissection. Nearly 10 % of patients present with
isolated headache or neck pain.
• Horner syndrome is seen in approximately 39 to 47 % of those with
carotid and up to 19 % of those with vertebral artery dissection
• Nearly 60 % of patients have brain ischemia or infarction.
• Ix of choice - MRI brain with angio

16. Evaluation of High risk features
• New headache in older adults without signs of raised ICT
• SOL, ICH, temporal arteritis should be kept in mind.
• In case of strong suspicion - CT brain, ESR, CRP

17. Evaluation of High risk features
• New headache in pregnancy
• Primary headache worsens during pregnancy.
• Preeclampsia, eclampsia after 20 weeks.
• PRES if hypertension is detected.
• CVT anytime during pregnancy.
• MRI with MRV

18. Evaluation of High risk features
• New headache in an immunosuppressed patient
• Infection, lymphoma, and leukemia are complications of chronic
immunosuppression
• CT with contrast

19. Evaluation of High risk features
• New headache in a cancer patient
• Metastases and, if the patient is immunocompromised, infection are
the primary concerns in this population.

21. Question 1
• 41/M k/c/o migraine with visual aura developed right sided neck pain
and headache that began 2 weeks prior while weight lifting. In 2
weeks he had episodes of right eye transient vision loss episodes. No
improvement with naproxen and sumatriptan. On examination, right
eye incomplete ptosis and miosis.
• Diagnosis?

23. Question 2
• Which of the following is incorrect about RCVS?
1. Common presentation is bilateral brief duration headache,
recurrent over span of days to weeks.
2. Vasoconstriction resolves over the period of 3 months.
3. Hallmark radiologic vasoconstriction develops 2-3 weeks after onset
of symptoms.
4. Triggers are carcinoid tumour, puerperium period, marijuana
substance abuse.
5. Presentation as thunderclap headache is less likely.

24. Question 3
• Which of the following is not a red flag sign for headache?
• Headache onset at Age > 50 years
• Headache associated with exertion
• Throbbing character of headache
• Headache in immunocompromised person.

25. Thank you