Headache: Difference between revisions
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===Non-specific Headache=== | ===Non-specific Headache=== | ||
* 1st line: [[ | * 1st line: [[prochlorperazine]] (compazine) 10 mg IV (+/- [[diphenhydramine]] 25-50 mg IV) + 1 L normal saline IV bolus | ||
**Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration | |||
* [[Ketorolac]] 30 mg IV | |||
** | |||
***Lower doses are shown to be just as effective<ref>Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Pt 2):116S-121S.</ref> | ***Lower doses are shown to be just as effective<ref>Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Pt 2):116S-121S.</ref> | ||
* | *Consider [[dexamethasone]] 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches | ||
* | *[[Opioid]] medications | ||
==See Also== | ==See Also== | ||
Revision as of 02:46, 17 September 2015
Background
- Headache accounts for ~2.2% of all ED visits[1]
- The majority of these have a benign cause, but serious causes can be devastating, and a thorough H&P with an eye toward "red flag" symptoms is important in ED evaluation.
Headache Red Flags
Features
- Sudden onset or accelerating pattern
- Maximum intensity of pain at onset (i.e. "thunderclap")
- Worse with valsalva
- Worse in the morning or at night
- No similar headache in past
- Age >50 yr or <5 yr
- Occipitonuchal headache
- Visual disturbances
- Exertional or postcoital
- Family or personal history of SAH, cerebral aneurysm, or AVM
- Focal neurologic signs
- Diastolic BP >120
- Papilledema
- Jaw claudication
Clinical Context
Headache in setting of:
- Infection
- Cancer
- Immunosuppression
- Seizure
- Syncope
- Trauma
- Altered mental status
- Systemic illness (fever, stiff neck, rash)
- Nausea/vomiting
- Patient on anticoagulation, steroids, NSAIDs, antiplatelet
Clinical Features
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[2] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity[3][4]. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% Sn
Differential Diagnosis
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
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
- If concern for ICH → non-contrast CT Brain ± Lumbar puncture
Imaging
- Consider non-contrast head CT in patients with:
- Thunderclap headache
- Worst headache of life
- 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
Management
- Treat specific headache type, if known
Non-specific Headache
- 1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L normal saline IV bolus
- Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
- Ketorolac 30 mg IV
- Lower doses are shown to be just as effective[5]
- Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches
- Opioid medications
See Also
References
- ↑ Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW; American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008 Oct;52(4):407-36. doi: 10.1016/j.annemergmed.2008.07.001.
- ↑ 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
- ↑ Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Pt 2):116S-121S.