Headache

Background

1. Opening pressure useful for SAH, cerebral venous thrombosis
2. LP is required if suspect SAH

DDx

Common

1. Migraine Headache
2. Tension Headache
3. Cluster Headache

Killers

1. Meningitis/encephalitis
2. SAH / sentinel bleed
3. Intracranial Hemorrhage (ICH) (subdura/epidural)
4. Acute obstructive hydrocephalus
5. Space occupying lesions
6. CVA
7. CO Poisoning
8. Basilar artery dissection
9. Preeclampsia
10. Cerebral Venous Thrombosis (pregnancy/post-partum)
11. Hypertensive Emergency
12. Depression

Maimers

1. Temporal Arteritis (>50yrs & ESR)
2. Idiopathic Intracranial Hypertension (pseudotumor cerebri)
3. Acute glaucoma
4. Acute sinusitis

Others

1. Trigeminal neuralgia
2. TMJ pain
3. Post LP/ low CSF
4. Dehydration
5. Analgesia abuse
6. Eye, dental, or derm cause
7. Febrile HA

Diagnosis

History

1. Time to maximal onset
2. Location
   1. Occipital - Cerebellar lesion, muscle spasm, cervical radiculopathy
   2. Orbital - Optic neuritis, cavernous sinus thrombosis
   3. Facial - Sinusitis, carotid artery dissection
3. Prior headache history

Physical Exam

1. Scalp and temporal artery palpation
2. Sinus tap / transillumination
3. Jolt test (have pt rapidly shake head side to side)
   1. 100% sensitive for meningitis
   2. "Most useful adjunctive maneuver for evaluating headache in the presence of fever"
4. Neuro exam

Laboratory Tests

1. If suspect temporal arteritis -> ESR
2. If suspect meningitis -> CSF studies
   1. Cannot use CBC to rule-out meningitis
   2. Add India Ink, cryptococcal antigen if suspect AIDS-related infection
3. If suspect CO poisoning -> carboxyhemoglobin level

Imaging

1. Consider non-contrast head CT in patients with:
   1. Thunderclap headache
   2. Worst headache
   3. Different headache from usual
   4. Meningeal signs
   5. Headache + intractable vomiting
   6. New-onset headache in pts with:
      1. Age > 50yrs
      2. Malignancy
      3. HIV
      4. Neurological deficits (other than migraine with aura)
   7. Consider CXR
      1. 50% of pts w/ pneumococcal meningitis have e/o PNA on CXR

Treatment

1. Migraine
   1. 1st line: Prochlorperazine (compazine) 10mg IV (+/- benadryl)
      1. Most effective therapy
   2. 2nd line:
      1. Metoclopramide (reglan) 10mg IV
      2. DHE 1mg IV (often used with an antiemetic)
         1. Contraindications: pregnancy, cardiovascular disease, HTN
      3. Triptans
         1. Contraindications: cardiovascular disease
   3. Ketorolac
2. Cluster
   1. Oxygen
   2. Triptans
   3. DHE
   4. Corticosteroids
   5. Verapemil
3. Tension
   1. NSAIDs

See Also

• Headache DDX
• Tension Headache
• Migraine Headache
• Cluster Headache
• Headache Red Flags
• CT Before LP

Source

EB Medicine, 06/01, vol 3, number 6

Annals 2008:52