Headache: Difference between revisions
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==See Also== | ==See Also== | ||
*[[Headache (Peds)]] | *[[Headache (Peds)]] | ||
*[[Postpartum headache]] | |||
*[[Headache Red Flags]] | *[[Headache Red Flags]] | ||
*[[CT Before LP]] | *[[CT Before LP]] |
Revision as of 17:53, 20 October 2014
Background
- Opening pressure useful for SAH, cerebral venous thrombosis
- LP is required if suspect SAH
DDx
Headache
Common
Killers
- Meningitis/encephalitis
- Myocardial ischemia
- Retropharyngeal abscess
- Intracranial Hemorrhage (ICH)
- SAH / sentinel bleed
- Acute obstructive hydrocephalus
- Space occupying lesions
- CVA
- Carbon monoxide poisoning
- Basilar artery dissection
- Preeclampsia
- Cerebral venous thrombosis
- Hypertensive emergency
- Depression
Maimers
- Giant cell arteritis of temporal artery (temporal arteritis)
- Idiopathic intracranial hypertension (Pseudotumor Cerebri)
- Acute Glaucoma
- Acute sinusitis
- Cavernous sinus thrombosis or cerebral sinus thrombosis
- Carotid artery dissection
Others
- Trigeminal neuralgia
- TMJ pain
- Post-lumbar puncture headache
- Dehydration
- Analgesia abuse
- Various ocular and dental problems
- Herpes zoster ophthalmicus
- Herpes zoster oticus
- Cryptococcosis
- Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
- Ophthalmoplegic migraine
- Superior Vena Cava Syndrome
Aseptic Meningitis
- Viral
- Tuberculosis
- Lyme disease
- Syphilis
- Leptospirosis
- Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
- Noninfectious
Diagnosis
History
- Time to maximal onset
- Location
- Occipital - Cerebellar lesion, muscle spasm, cervical radiculopathy
- Orbital - Optic neuritis, cavernous sinus thrombosis
- Facial - Sinusitis, carotid artery dissection
- Prior headache history
Physical Exam
- Scalp and temporal artery palpation
- Sinus tap / transillumination
- EBQ: Jolt Test
- Neuro exam
Jolt Test
- Horizontal rotation of the head at frequency of 2 rotations/second - exacerbation of pre-existing headache is positive test.
- Although a 1991 study[1] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity[2][3]. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% Sn
Laboratory Tests
- If suspect temporal arteritis -> ESR
- If suspect meningitis -> CSF studies
- Cannot use CBC to rule-out meningitis
- Add India Ink, cryptococcal antigen if suspect AIDS-related infection
- If suspect CO poisoning -> carboxyhemoglobin level
Imaging
- Consider non-contrast head CT in patients with:
- Thunderclap headache
- Worst headache
- Different headache from usual
- Meningeal signs
- Headache + intractable vomiting
- New-onset headache in pts with:
- Age > 50yrs
- Malignancy
- HIV
- Neurological deficits (other than migraine with aura)
- Consider CXR
- 50% of pts w/ pneumococcal meningitis have e/o PNA on CXR
Treatment
- Migraine
- 1st line: Prochlorperazine (compazine) 10mg IV (+/- benadryl)
- Most effective therapy
- 2nd line:
- Metoclopramide (reglan) 10mg IV
- DHE 1mg IV (often used with an antiemetic)
- Contraindications: pregnancy, cardiovascular disease, HTN
- Triptans
- Contraindications: cardiovascular disease
- Ketorolac
- 1st line: Prochlorperazine (compazine) 10mg IV (+/- benadryl)
- Cluster
- Oxygen
- Triptans
- DHE
- Corticosteroids
- Verapemil
- Tension
- NSAIDs
See Also
Source
EB Medicine, 06/01, vol 3, number 6
Annals 2008:52
- ↑ Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
- ↑ Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
- ↑ Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8