Headache Benjamin Katz MD Case Study 28

Headache Benjamin Katz, MD

Case Study 28 yo W c/o sudden onset posterior headache that awoke her from sleep. She also c/o nausea/vomiting and neck stiffness. n AMPLE: no meds, nkda, no PMHx, last ate dinner n

Case Study n Vitals: HR 110 BP 180/105 RR 20 s. PO 2 99 AAOx 3, uncomfortable PERRL, stiff neck RRR, CTAB MAEx 4, normal sensorium n Ddx? n n

Headache Classification Critical Secondary n Vascular – Subarachnoid Hemorrhage – Intraparenchymal Hemorrhage – Epidural Hematoma – Subdural Hematoma – Stroke – Cavernous Sinus thrombosis – Arteriovenous Malformation – Temporal Arteritis – Carotid or Vertebral Artery Dissection n CNS Infection – – – n n Glaucoma Iritis Optic neuritis – – – n Meningitis Encephalitis Cerebral Abscess Nitrates MAOI’s Alcohol Withdrawal – CO poisioning Tumor Pseudotumor Cerebri Opthalmic Drug Related Toxic

Headache Classification Critical Secondary (cont) n Endocrine – Pheochromocytoma n Reversible Secondary n Non-CNS Infections – – – Metabolic – – Hypoxia Hypoglycemia Hypercapnia High altitude cerebral edema – Preeclampsi n Focal Systemic Sinusitis Odontogenic Otic Drug Related – Chronic Analgesia use – MSG n Post Lumbar Puncture

Headache Classification Primary Headache Syndromes n Migraine n Tension n Cluster

Migraine n n n Onset in teens 5% men, 15 -17% women Peak age 40 Aura: primary neuronal dysfunction: spreading hypoactivity correlating with reduced blood flow Headache: related to activation of sensory area, release of inflammatory peptides, increased blood flow

ICHD-2 Migraine without Aura n n 5 attacks fulfilling the below Headache lasting 4 -72 hours At least 2 of – Unilateral location – Pulsating quality – Moderate/severe pain intensisty – Aggravation by physical activity Associated with at least 1 of – Nausea and/or vomiting – Photophobia and phonophobia

Migraine with aura similar, but with up to 60 minutes of any of visual scotoma, hemiparesis or aphasia n Aura without migraine n Without prior history, diagnosis of exclusion n

Migraine n Treatment – Quiet, dark area – IVF for nausea/vomiting – Ergot or triptans – Antiemetics (reglan, phenergan, keterolac, droperidol, compazine) – Maintenance (beta-blockers)

Tension Headache (ICDH-2) n Infrequent episodic TTH – 10+ episodes less than 1 per month and 12 per year with the following – 30 min- 7 days – 2 of the following n n Bilateral Non-pulsating pressure Mild/moderate intensity Unrelated to activity – Both of the following n n No nausea or vomiting Either one of photophobia or phonophobia n Frequent TTH – >1, <15 per month for 3 months n Chronic TTH – >15 per month, >3 months n Treatment – NSAIDS first line – If severe, same as migraine

Cluster Headache n n Rare, 0. 4% population, short without treatment, secondary to trigeminal nerve dysfunction Severe, unilateral, orbital or temporal pain lasting 15 -180 minutes Associated with conjunctival injection, lacrimation, nasal congestion, rhinorrhea, miosis, ptosis Treatment: high flow O 2, ergots, triptans (NSAIDs for maintenance)

Red Flags for Headache n n n Sudden Onset: SAH, AVM or mass lesion Worsening pattern: Mass, SDH, medication overuse Headache with fever, stiff neck or rash: meningitis, encephalitis, lyme, systemis infection, collagen vascular disease, arteritis Focal neuro signs: Mass lesion, AVM, collagen vascular disease, CVA Trigger with cough, exertion, valsalva: SAH or mass Pregnancy/postpartum: sinus thrombosis, carotid dissection, pituitary apoplexy

Red Flags Continued n New Headache in patient with – Cancer: metastasis – Lyme disease: meningitis – HIV: opportunistic Infection, tumor

Subarachnoid Hemorrhage n n n n 1/10, 000 in U. S. Young, median age 50 50% mortality at 6 months 50% with initially normal exam, vitals, absence of neck stiffness Caused by anneurysm or AVM rupture Diagnosis: CT detects 93% in 24 hr, 80% after 24 hr Treatment: support ABCs, definitive treatment is coiling or clipping

Intraparenchymal Hemorrhage n n 55% report headache at onset of symptoms Suspicion if hypertension, known mass, bleeding diathesis, trauma Support ABCs REMO protocol Hypertensive Emergency if SBP>220, DBP>120 – EKG, IV, O 2, monitor – NTG, metoprolol for chest pain, pulm edema

Epidural Hematoma n n n Tear in middle meningeal artery or rarely dural sinus Direct trauma with LOC, lucid interval progressing to coma Also consider if lethargy, vomiting, headache, ipsilateral dilated pupil (herniation)

Subdural Hematoma n n Hematoma between dura mater and subarachnoid due to tearing of bridging veins Consider with history of falls, head trauma, Et. OH, elderly, anticoagulation Suspect if bruise or scalp lac, lethargy, vomiting, headache, ipsilateral dilated pupil Treatment: support ABCs, definitive treatment is neurosurgical evacuation

Stroke n n 80% ischemic (thrombus, embolus, hypoperfusion) Hemorrhagic (IPH, SAH) – Risk if HTN, elderly, prior CVA, Asian and Blacks > whites, bleeding diathesis, vascular malformation, cocaine use n n Consider thrombus if HTN, CAD, DM Embolus if A-fib, Valve replacement, recent MI

Stroke n n n If h/o TIA with same distribution, then consider thrombus, if different distribution consider embolus Sudden onset suggests hemorrhage or embolus Gradual onset suggests thrombus or hypoperfusion

Assessment n n n Level of Consciousness Vision (fields and eye movement) Motor (strength, pronator drift) Cerebellar function (gait, finger to nose, heel to shin) Sensation and Neglect Language – Dysarthria: inability to articulate – Aphasia: defect in language processing n Cranial Nerve

Cincinatti Prehospital Stroke Scale n n n Facial Droop -Normal: Both sides of face move equally well. -Abnormal: One side of face doesn’t move as well as other side. Arm Drift -Normal: Both arms move the same or both arms don’t move at all. -Abnormal: One arm doesn’t move or one arm drifts down compared to the other. Speech (Ask patient to say “The sky is blue in Cincinatti”) -Normal: Patient says correct words without slurring -Abnormal: Patient slurs words, says wrong words or is unable to speak.

REMO protocol n n Draw a blood sample, check the blood glucose level, and establish IV access. If the patient is a diabetic, treat as per the Diabetic Emergencies Protocol. If taking an opiate or analgesic medication, treat as per the Overdose Protocol. Monitor the EKG, CNS status and vital signs every 10 minutes. Begin transportation and notify the destination hospital as soon as possible.

Stroke Therapy n n Important to identify exact time patient last had normal exam for potential thrombolytic therapy (t. PA) Lysis if >18 yo, clinical diagnosis of ischemic CVA, onset less than 3 hours n Exclusion – – – – – minor symptoms rapid improvement prior ICH fs <50 or >400, seizure GI/GU bleeding within 21 days recent MI surgery within 14 days, sustained SBP>185 or DBP>110 CVA or head injury within 90 days anticoagulant use thrombocytopenia

Temporal Arteritis n Autoimmune Vasculitis characterized by – – – – n n temporal headache visual disturbance (amaurosis fugax) claudication (masseter, temporalis tongue) Scalp tenderness Pulsating temporal artery (absent late stage) Decreased visual acuity Weakness Weight loss Patients >50 yo, women>men, 15 -30 per 100, 000 Treatment with steroids, biopsy for definitive diagnosis, risk for blindness if untreated

Carotid or Vertebral Dissection n Characterized by – – – n Headache Vertigo Unilateral Horner Syndrome Suspect if sudden neck rotation or extension urgent imaging and neurosurgery

CNS Infection n Protect yourself first – Fever + headache=mask n Meningitis: inflammation of arachnoid and pia mater caused by bacteria, virus or fungi – Headache, stiff neck, fever, chills, photophobia, confusion, phonophobia, nausea, vomiting, seizures (more common in children), rash, petechiae, Brudzinski or Kernig signs – Bacterial in 400 per 100, 000 children, 1 -2 per 100, 000 adults – Long term complications of cognitive defects, epilepsy, hydrocephalus, hearing loss

CNS Infection (cont) n n Infection via subarachnoid space (encapsulated organisms), also at risk if head trauma, neurosurgery, immune suppression Viral meningitis-- typically less severe illness: enterovirus, mumps, CMV, HSV, adenovirus, HIV Fungal– may be severe, consider if immunosupressed Treatment: Support ABCs, treat for shock/sepsis…definitive therapy is abx

CNS Infections continued n Viral Encephalitis: infection of brain parenchyma (arbovirus, HSV, HVZ, EBV, CMV, Rabies, equine encephalitis, West Nile) – New psychiatric sx, cognitive defect, seizures, movement disorders – Treatment with antivirals

CNS Infections (cont) n Brain Abscess: uncommon infection extending from otitis, hemotogenous or instrumentation – Classic fever, headache, focal neuro deficit in less than one third – Symptoms from focal and mass effect cause delayed diagnosis – Diagnosis with imaging, LP, +/- biopsy – Treatment: support ABCs, antibiotics

n n Tumor: 70% with headache, classically worse in the morning, positional, nausea and vomiting Pseudotumor cerebri: headache worse with awakening, valsalva, cough, bending – Signs of increased ICP: papilledema, CN VI palsy, diploia, visual deficits, tinnitus – Linked with OCP use, vit A, tetracycline use, thyroid disorders – Diagnosed with CT for hydrocephalus, LP for high opening pressure – Treatment diuretics, repeat LP, CSF shunt or optic nerve sheath fenestration

Opthalmic n Glaucoma – Acute angle closure: obstruction of aqueous humor outflow leading to increased intraocular pressure and possible blindness – Sudden onset painful vision loss associated with headache, nausea, vomiting, somnolence – Exam with decreased vision, conjunctival injection, hazy cornea, fixed/mid-position or dilated unreactive pupil – Needs emergent opthomology referral, eye gtts

Opthalmic n Iritis: inflamation of the Iris – Risk if sarcoid, STDs, collagen vascular dz – Blurred vision, deep eye pain, photophobia, red eye – Exam with conjunctival injection, cell and flare – Optho referral, topical steroids, cycloplegic drops n Optic Neuritis: painful vision loss due to inflammation of optic nerve – Consult with opthomology regarding iv steroids

Drug Related Headache n n n Nitrates: symptomatic hypotension, hypoperfusion MAOIs: orthostatic hypotension, but can have hypertensive crisis when taken with sympathomimetic amines, l-dopa, narcotics or tyramine containing foods (cheese) Alcohol withdrawal: treat with benzodiazepines

Toxic n Carbon Monoxide Poisoning – CO competes with O 2 for Hgb binding with 250 x affinity – Suspect with confined space fire, car engine left on, several household members sick at same time – Half life 320 min @ RA, 82 min @ 100 %NRB, 23 min @ 3 atm HBO – Headache, nausea, vomiting, malaise, chest pain, weaknes, apathy, cherry red skin, abnormal reflexes, altered mental status – Treat with O 2, consider transfer to hyperbarric chamber

Metabolic n n n Hypoxia Hypoglycemia Hypercapnia High Altitude Cerebral Edema – – – Due to acute hypoxia from rapid ascent Higher risk if pulm dz, Et. OH/drug use, dehydration Headache, anorexia, nausea, vomiting, weakness, altered mental status seizure/coma/death – Treat with immediate descent, 100%O 2, Dexamethasone +/- HBO Preeclampsia: after 20 th week of pregnancy—BP >160/110, proteinuria, peripheral edema – May progress to eclampsia (above + seizures) – Definitive treatment is delivery, may use hydralazine for HTN, magnessium sulfate for seizure

Non-CNS Infection n Systemic– viral syndromes, bacteremia, fever may often cause generalized headache – Antipyretic for fever, definitive treatment for source of infection n Sinusitis– inflammation of ethmoid, frontal, sphenoid or maxillary sinus – Fever, malaise, anosmia, headache and toothache, purulent discharge, postnasal drip, sore throat, facial pain/pressure – Antibiotics and nasal decongestants, antipyretics for fever and analgesia

Non-CNS Infections n Dental Infections—Caries and/or periapical abscess – Toothache, jaw pain, earache, jaw pain, tooth tender to percussion – Treatment involves covering exposed tooth, analgesia, abscess drainage if appropriate n Ear Infections – Otitis Media– middle ear infection with ear pain/fullness, decreased hearing, vertigo, fever. Treat with antibiotics, antipyretics – Otitis Externa– External Ear infection with itching, decreased hearing, fever, tender external ear. Treated with antibiotic drops. Caution if diabetic for malignant OE

Post Lumbar Puncture n Headache is secondary to loss of CSF – – – Persistent headache due to CSF leak after LP Definitive Treatment is Blood Patch Keep patient supine +/- Trendellenberg

Cases n 56 yo W with throbbing right sided headache, “darkened” vision on the right

Cases n 21 yo W with throbbing left sided headache for 1 day preceded by seeing bright lights

Cases n 45 yo HIV+ M c/o several day h/o headache, blurred vision, vertigo, nausea and vomiting

Cases n 65 yo M w/ CAD and HTN with acute onset of dysarthria, right sided weakness

Cases n 22 yo M w/ fever, stiff neck and

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