The Acute Headache Devorah Nazarian, M.D. Mount Sinai School of Medicine April 12, 2002.
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Transcript of The Acute Headache Devorah Nazarian, M.D. Mount Sinai School of Medicine April 12, 2002.
The Acute HeadacheThe Acute Headache
Devorah Nazarian, M.D.
Mount Sinai School of Medicine
April 12, 2002
Patient PresentationPatient Presentation
• HPI-35 y.o. female presents to the E.D. complaining of a severe headache. The patient states that she was on the subway going to work, a few hours ago, when she suddenly felt a severe sharp pain in her head. Associated symptoms include nausea, neck pain. Patient took Ibuprofen prior to arrival with no relief.
• PMH- Prior history of headaches which resolve with ibuprofen.
• Social-Denies alcohol or cocaine. Smokes “few” cigarettes on weekends
• Meds- OCP
Patient Presentation continuedPatient Presentation continued
• P.E.-Vitals Temp 97.4 BP 122/74 HR 90 RR 16 General: appears in discomfort with eyes shut Neuro: A&Ox3, CN II-XII intact, Motor 5/5 throughout, nl gait, sensory grossly intact, reflexes equal throughout HEENT: PERRL, EOMI, NCAT Neck: supple, -nuchal rigidity Chest: CTA-B Heart: RRR -M Abdomen: +bs, soft,ND, NT Extremities: FROM, -C/C/E Skin: no rashes, no signs of trauma
IntroductionIntroduction
• 1-3% of E.D. visits are for headache.• Only 1-5% of those patients have a
serious underlying problem.
Causes of a HeadacheCauses of a Headache• distention, traction, or dilation of
intracranial or extracranial arteries• traction or displacement of large
intracranial veins or dural envelope• compression, spasm, inflammation, and
trauma to cranial & spinal nerves • spasm, inflammation, and trauma to
cranial & cervical muscles• meningeal irritation & raised intracranial
pressure• disturbance of intracerebral serotonergic
projections
Common Pathway for Pain Regardless of Common Pathway for Pain Regardless of Underlying Etiology of the HeadacheUnderlying Etiology of the Headache• HA pain of the scalp and face is
transmitted via trigeminal nerve • Regardless of the etiology once the
trigeminovascular axons are stimulated a pathway starts resulting in the onset of pain
• Serotonin receptors are the main focus of pain management.
• The 5-HT1 receptor is thought to be the most important subtype in the common pathway of headache
Response of Headaches in Nonnarcotic Response of Headaches in Nonnarcotic Analgesics Resulting in Missed Intracranial Analgesics Resulting in Missed Intracranial
HemorrhageHemorrhage• Case series• Presented 3 patients with headaches whose
symptoms resolved with a variety of medications but returned with hemorrhage.
• Concluded that patients can have significant pathologic hemorrhage after successful treatment with nonnarcotic analgesics and release from the ED
Seymour JJ, Moscati RM, Jehle DV,. Response of Headaches to Nonnarcotic Analgesics Resulting in Missed Intracranial Hemorrhage. AM J Emerg Med . 1995;13:43-45
Dihydroergotamine and Metoclopramide Dihydroergotamine and Metoclopramide in the Treatment of Organic Headachein the Treatment of Organic Headache• Case series• Patients were given nonnarcotic agents
with complete pain relief and found to have inflammatory intracranial processes.
• Using response to pain can as indicator of etiology may miss potential problematic headache
Gross DW, Donat JR, Boyle CA, Dihhydroergotamine and metocloperamide in the treatment of organic headache. Headache. 1995;35:637-638
Sumatriptan Relieves Migraine-like Sumatriptan Relieves Migraine-like Headaches Associated with CO Headaches Associated with CO
ExposureExposure
• Case report• One patient with a headache from CO
poisoning who responded to sumatriptan
Lipton RB, Mazer C, Newman LC, et al. Sumatriptan relieves migraine-like headaches associated with carbon monoxide exposure. Headache. 1997;37:392-395.
Patient Management Patient Management RecommendationRecommendation
• Level C Recommendation. Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.
What Is the Goal of What Is the Goal of Neuroimaging in the ED?Neuroimaging in the ED?
• To identify a treatable lesion.• ACEP has categorized neuroimaging
• Emergent- essential for a timely decision regarding potentially life-threatening or severely disabling entities
• Urgent- arranged prior to discharge from the ED or, performed prior to disposition when follow-up cannot be assured
• Routine- indicated when the studies results are not considered to make a change in the patients disposition from the ED
Patients With Headache and Patients With Headache and Abnormal Neurologic Exam Require Abnormal Neurologic Exam Require
NeuroimagingNeuroimaging • US Headache Consortium, reviewed
articles dealing with chronic headache• abnormality on neurologic exam increased
the likelihood of positive results in a neuroimaging by 3 fold
• normal findings in a neurologic exam reduced the odds of positive findings in a neuroimaging study by 30%
US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000
Predictors of Intracranial Pathologic Predictors of Intracranial Pathologic Findings in Patients Who Seek Findings in Patients Who Seek
Emergency Care Because of HeadacheEmergency Care Because of Headache• retrospective random chart review • 468 patients who presented to the ED with
chief complaint of headache• abnormal findings in neurologic exam had
a PPV for intracranial pathology of 39% • age greater than 55 was identified as
clinical parameters associated with intracranial process
• no association found between type of HA and the final diagnosis
Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of Headache. Arch Neurol. 1997;54:1506-1509
Practical Selection Criteria for Practical Selection Criteria for Unenhanced Cranial CT in Patients With Unenhanced Cranial CT in Patients With
Acute HeadacheAcute Headache• retrospective review • ED patients complaining of acute HA or
acutely worsening HA• 333 patients evaluated• 17 patients had “worst headache of life”;
only one had positive CT results• Does not support work-up for patients
with worst headache• Flawed Study
Reinus WR, Wippold FJ, Erickson KK. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache. Emerg Radiol. 1994;94:67-70
Acute Headache of Recent Onset Acute Headache of Recent Onset and Subarachnoid Hemmorrhageand Subarachnoid Hemmorrhage• 1 year prospective study• acute sudden-onset HA with normal
neurologic findings• all patients had CT, if CT was negative LP
done• patients were followed for 3 months• 27 patients enrolled, 9 had SAH, 1
intraventricular hemorrhage, 1 bacterial meningitis, 1 with viral meningitis
• supports neuroimaging for patients with sudden acute onset headache
Lledo A, calandre L, Marinez-Menendez B, et al. Acute Headache of Recent Onset and Subarachnoid Hemmorrhage: a Prospective Study. Headache. 1994;34:172-174
Further Support for Neuroimaging Further Support for Neuroimaging with Severe Headachewith Severe Headache
• Harling in a prospective study of patients presenting with thunderclap headache found 35/49 to have SAH on CT or LP.
• Mills in a prospective study found that 29% of patients receiving head CT for “worst headache of life” had positive CT findings.
• Both studies support imaging for acute sudden-onset headache
Harling DW, Peatfield RC, Van Hille PT, et al Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90 MillsML, Russo Ls, Vines FS, Et al . High yield criteria for urgent cranial CT scans. Ann Emerg Med. 1986;15:1167-1172
Headache in HIV Related DisordersHeadache in HIV Related Disorders
• Prospective study• 49 consecutive HIV patients with
headache• 82% had a serious identifiable cause. • HIV positive patients with headache
should be considered for CT and LP
Lipton RB, Feraru ER, Weiss G, et al. Headache in HIV Related Disorders. Headache. 1991;31:518-522
A Decision Guideline For ED Utilization A Decision Guideline For ED Utilization of Noncontrast Head CT in HIV Infected of Noncontrast Head CT in HIV Infected
PatientsPatients• prospective convenience sample• 110 patients with neurologic complaints• new seizure, depressed or altered mental
status, and headache that was different in character or lasted longer than 3 days, identified all the cases of focal lesions in patients
• new or different HA was reported in 25% of the cases
Rothman RE, Keyl PM, McArthur JC, et al . A decision guideline for the utilization of noncontrast head CT in HIV infected patients. Acad Emerg Med. 1999;6:1010-1019
Patient Management Patient Management RecommendationsRecommendations
• Level B Recommendations. Patients presenting to the ED with headache and abnormal findings on neurologic examination should undergo emergent noncontrast head CT. Patients presenting with acute sudden-onset headache should be considered for emergent head CT scan. HIV positive patients with a new type of headache should be considered for urgent neuroimaging study.
• Level C Recommendations. Patients who are older than 50 years old with a new type of headache without abnormal finding on neurologic exam should be
considered for urgent neuroimaging.
Question # 3Question # 3
Is There a Need for Emergent Angiograghy in the Patient
with a “Thunderclap Headache” Who Has Negative Findings In Both CT and LP?
Thunderclap HeadachesThunderclap Headaches• sudden-onset headache of excruciating pain
reaching its maximal intensity within a few seconds
• suggest presence of subarachnoid hemorrhage (SAH)
• work-up: noncontrast CT and LP• Day and Raskin presented a patient with 3
thunderclap headaches (TCHA) in 1 week and a negative work-up. An angiogram showed diffuse vasospasm and an unruptured aneurysm.
• Could a TCHA be a sign of hemorrhage into the wall or rapid expansion of aneurysm.
Day JW, Raskin NH, Thunderclap Headache: symptom of unruptured aneurysm. Lancet 1986;2:68-70
Long-Term Follow-up of 71 PatientsLong-Term Follow-up of 71 PatientsWith TCHA Mimicking SAHWith TCHA Mimicking SAH
• prospective follow-up study• 71 patients who presented with TCHA with
negative CT and LP• followed for 3.3 years• none developed SAH in follow-up period• angiography is not needed in the work-up
of patients with TCHA
Wijdicks EF, Kerkhoff H, van Gijn J, Long-term follow-up of 71 patients with TCHA mimicking SAH. Lancet.1988,2:68-70
Vasospasm as a cause of TCHAVasospasm as a cause of TCHA• Case reports• total of 6 patients • angiography on all patients revealed
multifocal segmental vasospasm without aneurysm
• vasospasm is certainly one of the causes of TCHA
Slivka A, Philbrook B, Clinical and angiographic features of thunderclap headache. Headache.1995;35,:1-6Dodick DW, Brown RD, Britton JW, et al. Nonaneurysmal thunderclap headache with diffuse, multifocal, segmental, and reversible vasospasm. Cephalagia. 1999; 19:118-123
TCHA Is It a Migraine? TCHA Is It a Migraine? • prospective study• 49 patients with TCHA, 14 patients had
negative results• patients followed for a minimum 18
months without adverse outcomes• refutes the need for angiography in initial
work-up of TCHA
Harling DW, Peatfield RC, Van Hille PT, et al. Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90
The Clinical Spectrum of Unruptured The Clinical Spectrum of Unruptured Intracranial AneurysmsIntracranial Aneurysms
• 111 patients with unruptured aneurysms• 54 had symptomatic aneurysms• 8 clinical syndromes of symptomatic
unruptured aneurysms documented• 7 patients with TCHA• aneurysmal mechanism of TCHA included
aneurysmal expansion, thrombosis, and intramural hemorrhage
Raps EC, Rogers JD, GalettaSL, et al. The clinical spectrum of unruptured intracranial aneurysm. Arch Neurology. 1993;50:265-268
Identification and Treatment of Identification and Treatment of Cerebral Aneurysms after Sentinel Cerebral Aneurysms after Sentinel
HeadacheHeadache• case reports• 2 patients with prolonged TCHA negative
CT and LP• angiograms showed aneurysms• concluded that angiography needs to
remain part of the work-up for TCHA
Hughes RL. Identification and Treatment of Cerebral Aneurysms after Headache. Neurology. 1992;42:1118-1119
Other Entities Which Can Cause a Other Entities Which Can Cause a TCHATCHA
• cerebral venous thrombosis can present TCHA without neurologic findings
• vertebral artery dissection and internal carotid artery dissection often are associated a sudden severe headache
Patient Management Patient Management RecommendationsRecommendations
• Level C Recommendations. Patients with a thunderclap headache who have negative findings on noncontrast head CT, normal opening pressure and negative findings on CSF analysis do not need emergent angiography. These patients can be discharged from ED with follow-up arranged with their primary care provider or neurologist .