This document summarizes key points about evaluating and managing headaches in the emergency department setting. It discusses distinguishing between primary and secondary headaches, red flags to identify high-risk causes, appropriate use of imaging like CT scans and lumbar punctures, specific conditions like subarachnoid hemorrhage and meningitis, and antibiotic treatment for meningitis. Case examples are also provided to demonstrate history taking, exam, differential diagnosis, and management of headache patients.

1. PITFALL
MEETING
- HEADACHE
2015/12/4
黃建雄

2. 頭痛是個大學問啊

3. 沒想到大到有個學會吧

4. 身為一個急診醫師，關於頭痛你該知道些什麼?
• Primary vs. Secondary
• Red flags of High risk headache
• High risk causes of headache

5. PRIMARY VS. SECONDARY
• 重要嗎？
• Although headache are typically classified as primary
headaches when there is no underlying cause (such as
migraine or cluster headaches ) and secondary headaches
if associated with an underlying cause (such as tumor,
meningitis, or subarachnoid hemorrhage), this distinction
is not clinically useful in the ED setting.
- Tintinalli 8th ed
Although headaches are typically classified as primar
aches when there is no underlying cause (such as mi
or cluster headaches) and secondary headaches if
associated with an underlying cause (such as tumor,
meningitis, or subarachnoid hemorrhage), this distinc
not clinically useful in the ED setting.c

6. MIGRAINE
4-72 hrs on average

7. CLUSTER HEADACHE

8. RED FLAGS - SSNOOP
• Systemic signs (fever, weight loss),
• Secondary risk factors (immuno‐ compromised status, HIV,
Cancer),
• Neurological signs (speech deficit, cranial nerve
abnormalities, altered conscious),
• Onset – abrupt, sudden
• Older age – new onset headache >50y/o
• Progression of symptoms (changes in attack frequency
and severity)

9. By our Bible – Tintinalli, 8th ed

11. WHAT IS A
THUNDERCLAP
HEADACHE

13. HEADACHE
CASE
SCENARIO

14. CASE 1
34 y/o female
visit ER for severe headache 30 mins ago
PI:
Acute onset
whole head
“the worst headache of my life”
No recent head trauma
No focal weakness
No slurred speech
T: 36.8 P:115 R:20 BP:120/75

15. HISTORY TAKING
• Pattern
• constant, waxing, waning, different from previous headaches
• Onset
• Location
• Associated symptoms
• syncope, altered level of consciousness, neck pain/ stiffness,
persistent visual changes, fever, seizure
• Previous headache history
• Medications (anticoagulant)
• Toxic exposures (eg, carbon monoxide)
• Substance use history
• Relevant comorbidities
• HIV, malignancy, coagulopathy, hypercoagulable state, hypertension
• Family history
• Aneurysm, migraine, malignant

16. PHYSICAL
EXAMINATION
• Vital signs
• fever
• HEENT examination
• sinuses, temporal arteries, slit lamp examination,
funduscopy, tonometry
• Meningismus testing
• Examination of Eye
• Funduscope examination
• Neurological examination
• mental status, cranial nerves, motor and sensory function,
reflexes, cerebellar exam, gait, and station.

17. NEXT STEP?
• Pain was not relieving after your pain control

18. NON CONTRAST HEAD
CT OR NOT
In 2008, recommendation of ACEP:
1. 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 (Level B recommendation).
2. Patients presenting with new sudden-onset severe headache
should undergo an emergent head CT (Level B recommendation).
3. HIV-positive patients with a new type of headache should be
considered for an emergent neuroimaging study (Level B
recommendation).
4. Patients who are older than 50 years and presenting with new type
of headache but with a normal neurologic examination should be
consid- ered for an urgent (arranged prior to ED discharge)
neuroimaging study (Level C recommendation).

19. WHEN TO DO LUMBAR
PUNCTURE
In 2008, recommendation of ACEP:
• 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 B recommendations)
做了看什麼？
• Red blood cells (RBCs) and xanthochromia
• LP may be negative if performed less than 2 hours after an
SAH occurs; LP is most sensitive 12 hours after onset of
symptoms

22. ABOUT SAH
• About 5% of SAH are misdiagnosed on the 1st ED
assessment (Vermeulen, Stroke. 2007; 38: 1216-1221).
• 50% of SAH present with no neurologic deficit (Weir,
Cephalalgia April 1994 vol. 14 no. 2 79-87).

23. TREATMENT
• 預防再出血
• 保守治療
• 介入性治療（clip, coil）
• 血管痙攣的治療
• 水腦治療
• 體外腦室引流
• 腦室腹腔引流
• 癲癇
• 低血鈉的治療

24. CASE 2
34% female
Visit ER for Fever and headache for 3 days
PI:
Fever to 39 degree, intermittent
Severe headache, bilateral temporal area
No cough, no rhinorrhea
No dysuria, no abdomen pain
Upper back pain and posterior neck pain
Ever visited LMD, still headache and fever
T: 39.1 P: 110 R:20 BP 97/65 mmHg

25. Visit ER today due to right inguinal enlarged painful lymph
node
Past History: no systemic disease
Travel history: nil
Occupation: 文書
Contact history: nil

26. PHYSICAL
EXAMINATION

27. SCRUB TYPHUS
恙蟲病

28. 恙蟲病屬於第四類傳染病 , 應於一週內完成通報
傳染方式
–被具傳染性的恙蟎叮咬,經由其唾液使宿主感染立克次體
潛伏期
– 潛伏期6至21天,通常為9至12天
可傳染期
– 恙蟲病不會經由人傳染給人
感受性及抵抗力
– 感染後對同一型別的立克次體有長期的保護力,但 對不同型別此保
護力僅短暫存在
– 對於生活在流行地區的人,有可能第二次甚至第三 次遭受感染,不過
症狀通常較輕微

29. SIGNS AND
SYMPTOMS

30. 治療方法
– 四環黴素類抗生素,需遵從醫囑使用
預後
– 未經治療,死亡率可達百分之六十 – 經妥適治療後死亡率小於百分
之五

31. CASE 3
75 y/o female
Visits ER for vomiting and headache since 6 hours ago
Acute onset and severe headache
“the worst headache of my life”
Nausea and vomiting 3 times, epigastric pain after vomiting
Whole left temporal area pain
No focal weakness, no slurred speech
Blurred vision for long term
T: 37.3 P:114 R:18 BP:167/106

32. Visited LMD, AGE and viral syndrome was told.
No improvement
Past history
• DM under OHA control, Hypertension
• Aspirin use (+)
• No OP history
• No recent trauma

34. ACUTE ANGLE
CLOSURE GLAUCOMA
Eye pain or headache, cloudy vision, colored halos around
lights, and the patient may be vomiting.
Physical examination
• conjunctival injection,
• cornal clouding,
• fixed mid-dilated pupil,
• increased IOP of 40 to 70 mm Hg (normal range, 10 to 20
mm Hg)

35. TREATMENT

36. CASE 4
7 y/o boy
Brought to ER for fever to 39 degree for one day
Poor appetite, decreased activity
Complained of headache, neck pain, and back pain
Nausea and vomiting (+)
No cough, no sore throat, no rhinorrhea
T: 38.9 P: 108 R: 20 BP: 104/76
SpO2: 100%

39. Treat as AGE and viral syndrome after 1st visit of ER
Then his parents brought him to ER again one day latter
For seizure attack
His consciousness became drowsiness
Still high fever to 39 degree
Apparent neck stiffness
And some skin rash noted on lower legs
The rashes do not fade under pressure
T: 38.6 P: 154 R: 28 BP: 86/40 mmHg

40. MENINGOCOCCEMIA

41. LAB DATA
WBC: 16500 , Hb: 13.6, PLT: 17000
Seg: 89% Band: 6%
CRP: 156 , ALT: 40, Cr: 0.89, sugar: 109
INR: 1.4 aPTT: 33
Brain CT: no intracranial hemorrhage, no abscess

42. CSF STUDY
Open pressure: 29 cmH2O
Leukocyte: 4500, Neutrophil: 98%, Lym: 1%,
RBC: 0
Sugar: 16, Protein: 363, Lactate: 45
Gram stain: bacteria (+)

44. ANTIBIOTICS CHOICE
N . meningitidis
Inj Benzyle Penicillin 2.4 G IV 6th hrly * 5-7 days
Strep. pneumoniae / H. influenae
Inj Cefotaxime 2 G IV 6th hrly or
Inj Ceftriaxone 2 G IV 12th hrly * 10-14 days
Pinicillin Resistant pnuemococci
Inj Cefotaxime or Ceftriaxone + Inj Vancomycin 1gm IV 12th hrly
Listeria monocytogenes
Inj Ampicillin 2G iv 6 hrly
+ Inj Gentamycin 5g/kg iv * 8- 10 days

45. OTHER HIGH RISK
BUT RARE CAUSES

46. CEREBRAL VENOUS
THROMBOSIS
the diagnosis is made definitively with magnetic resonance
venography

48. CAVERNOUS SINUS
THROMBOSIS
• High mortality rate
• Antibiotics for septic Cavernous sinus thrombosis

49. Thank you for your attention!