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Senior - E Med > 3 - Headache > Flashcards

3 - Headache Flashcards

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1
Q

5th MC reason to go the ED?

A

Headache

2.1 million visits/yr

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2
Q

Though 47% or adults suffer from HA only __ are high risk?

With Acute onset aka ___, __ - __ are high risk

A

4%

Thunderclap HA
10-14%

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3
Q

Primary vs secondary HA?

A

Primary: ideologic

Secondary: underlying cause i.e. tumor, subarachnoid hemorrhage

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4
Q

Name some red flags:

A

Onset: sudden, trauma

Sympsoms: altered mental, seizure, fever, visual changes

Meds: Abx, anticoagulants, immunosuppressants

Past hx: change in normal Ha

Associated: preggo, lupus, sarcoidosis

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5
Q

PE red flags with HA

A 
altered mental status 
fever, 
neck stiff, 
papilledema,
focal neuro signs
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6
Q

Meningitis triad?

A

Fever
Altered mental status
Neck stiffness

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7
Q

If you suspect meningitis but cannot get LP (i.e. pt is combative, has coagulopaty etc) you should?

A

Treat with abx

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8
Q

Worst HA of my life is pathognomonomic for subarachnoid hemorrhage, but how many of theses people actually have it?

A

10-14%

But it has a 50% survival at 30 days so we care

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9
Q

What is xanthochromia?

A

A yellow tinge to CSF that indicates a subarachnoid hemorrhage

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10
Q

Steps needed to r/o SAH?

A 
CT 
If neg
LP 
If neg and hx really suggest
Call neuro
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11
Q

Who is getting a CT for a HA regardless of symptoms?

A

People on antiplatlets and anticoagulants

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12
Q

Acute HA w associated vestibular symptoms?

A

(Vertigo or ataxia)

Considered cerebellar hemorrhage until proven otherwise

You’re getting a surgical evacuation

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13
Q

What about a brain tumor causes a HA?

A

CSF obstruction

intracranial Hypertension

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14
Q

Signs suggesting brain tumor?

A

HA with:

Abnormal neuro
Worsened by valsalva
Awakening from sleep
Seizures
Cancer diagnosis
Mental status change
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15
Q

Study or choice for brain tumor?

A

MRI with and w/o gandolinium

CT will see large masses but isnt as good

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16
Q

Pts with new onset HA you need to worry about?

A

Cerebral venous thrombosis

Presentation can vary greatly

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17
Q

Known risk factors for cerebral venous thrombosis?

A

Women
Peripartum
Recent surg hx
Hypercoagulable states

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18
Q

Cerebral venous thrombosis presentation?

A

Varies greatly from benign to seizure, stroke and coma

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19
Q

If abnormal CT or MRI with focal neurologic deficit or altered mental you need to order? (Definitive diagnosis)

A

Magnetic resonance venography

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20
Q

Cerebral venous thrombosis LP?

A

Yes you can safely do it

Elevated opening pressure prompts more tests

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21
Q

What is posterior reversible encephalopathy syndrome?

A

Encephalopathy symptoms
Marked BP elevation
MRI: symmetrical vasogenic edema in occipital area

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22
Q

TX for posterior reversible encephalopathy syndrome?

A

BP management

Supportive care

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23
Q

What can mimic subarachnoid hemorrhage?

A

Reversible cerebral vasoconstriction syndrome

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24
Q

Warning signs for reversible cerebral vasoconstriction?

A
  • Multiple “thunderclap” HA w/in a few weeks
  • Subarachnoid hemorrhage is neg
  • Women in early 40’s
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25
Though some pts with reversible cerebral vasoconstriction syndrome present with seizures and focal neuro ___ is often the only presenting symptom.
severe headache
26
What is the key diagnostic feature of reversible cerebral vasoconstriction syndrome?
Multiple areas of cerebral vasoconstriction on cerebral angiography Usually found between 2 and 3 weeks after onset
27
Imaging can take weeks and is sometimes not clear so diagnosis of reversible cerebral vasoconstriciton syndrome is often made by?
Presentation of thunderclap HA W/o subarachnoid hemorrhage This should at least prompt a consult with neuro
28
Pt presents with: - Fatigue - fever - proximal muscle weakness - jaw claudication - TIA symptoms (transient vision loss)
Temporal arteritis | Aka “giant cell arteritis”
29
Temporal arteritis must have what labs?
ESR must be high | Check IOP to exclude glaucoma
30
Tx for temporal arteritis?
Prednisone 60mg q day
31
Giant cell arteritis must have 3 out of 5 of the following for diagnosis:
- >50 yrs - new HA - temporal artery abnormality (TTP etc) - ESR >/=50 - abnormal artery biopsy
32
Migraine is defined as:
HA with: - moderate - severe - lasts 4 -72 hrs - unilateral/pulsatile (usually) - photophobia and phonophobia - made worse by activity
33
Definition of chronic migraine?
5+ migraine HA days per month over 3 months
34
1st line abortive therapy for migraines?
Triptans are first line abortive therapy
35
If abortive therapy fails pts get rescue therapy which is:
IV hydration NSAIDS Antiemitic Diphenhydramine (20-50mg IV)
36
Diphenhydramine helps with migrains b/c histamine levels correlate with migraine attacks but what else does it do?
Helps treat akathisias from antiemetics
37
What are akathisias?
A feeling of muscle quivering, restlessness, and inability to sit still, sometimes a side effect of antipsychotic or antidepressant medication.
38
Tx options for migrains
Chart on 29 and 30 I’ll make cards if he makes a big deal about it
39
Pregnancy considerations for migraines?
No good data but: Tylenol, opoids, steroids: yes Metoclopramide : yes NSAIDS: until 3rd trimester Triptans: NO Ergotamines: FUCK NO
40
ED fixes migraines right?
Not usually. Over 1/2 will have some residual HA You send them home with abortive meds
41
Who gets idiopathic intracranial hypertension?
Obese women between 20 and 44 yrs and has trended up with obesity epidemic
42
Idiopathic intracranial hypertension is aka?
Pseudotumor cerebri
43
Symptoms of pseudotumor cerebri?
HA Transient visual obscurations (32%) Back pain Puslsatile tinnitis
44
If you dont treat idiopathic intracranial hypertension what do you win?
Can lead to permanent visual impairment
45
Diagnostic criteria for idiopathic intracranial hypertension?
- Papilledema (otherwise normal neuro) - H opening pressure on LP — >25 in adults and >28 in kids - normal CSF composition - normal imaging
46
In the absence of either papilledema or abducens nerve palsy diagnosis of pseudotumor without papilledema can be made if at least 3 of the following?
1. Empty sella 2. Flattening of posterior aspect of globe 3. Distension of perioptic subarachnoid space 4. Tortuous optic nerve 5. Transverse venous sinus stenosis
47
What is both diagnostic and therapeutic for pseudotumor cerebri?
LP: needed for diagnosis | - lowered pressure provides temporary relief
48
How much does each ml of CSF lower CSF fluid pressure (in general) What if i remove too much?
1mL of CSF with lower Pressure by 1cm H20 Low pressure HA
49
Meds for idiopathic intracranial hypertension?
acetazolamide PO 250-500mg BID Up to 4gm/day but adjust dose under supervision of neuro
50
Long term tx for pseudotumor cerebri may include?
Shunting of CSF Optic nerve sheath fenestration Wt loss (LOL)
51
Cluster HA may mimic?
Dental pain
52
Distinguishing feature for cluster HA?
The need to pace
53
Tx for cluster HA?
100% O2: 12L/min x 15 min - NRB Sumatriptan 6mg SC
54
Cluster HA must have at least 5 attacks with the following criteria:
Severe Unilateral 15-180 min Circadian/circannual
55
Associated ipisilateral symptoms for cluster HA?
Pt must have at least 1 ``` Lacrimation Conjunctival injection Nasal conjunction Ptosis and/or miosis Edema or eyelid/face Sweating of forehead/face ```
56
How is coital HA diagnosed?
Diagnosis of exclusion Must have imaging
57
What is a valsalva associated HA?
Thunderclap HA triggered by valsalva, cough, straining with normal neuroimaging
58
Severe HA in older pts?
Bad sign, cluster, tension and migraine HA incidence decrease with age so this is not promising
59
What is a intracerebral aneurysmal leak?
Aka sentinal hemorrhage or herald bleed Can precede catastrophic aneurysmal rupture
60
Fever with HA raises concerns for?
CNS infection - meningitis - encephalitis - brain abscess
61
Family hx of autosomal dominant polycystic kidney disease has an increased risk for?
Intracranial aneurysm
62
Why must acute angle-closure glaucoma be considered with severe HA?
The pain can be so sever that the pt may fail to localize pain to the eye
63
___ can be seen in the presence of raised ICP
Papilledema Can persist after ICP drops
64
Lab tests for HA?
Routine blood tests dont help much but we still look at: - BMP - CBC - Coagulation panel (coags) - ESR - blood culture - CSF analysis
65
You come to the ED with a HA what imaging are you getting?
Depends on HX PE bla bla bla Youre probably getting a non contrast CT
66
When is MRI useful in HA?
Detecting arterial disease - stenosis - congenital anomalies - dissection - CNS vasculitis Radiology can recommend which type of MRI is best
67
LP is warranted for which HA’s?
Diagnostic: - Meningitis - SA hemorrhage - intracranial HOTN - Carcinomatous meningitis Therapeutic: - Pseudotumor cerebri
68
Factors that indicate LP is probably safe?
No hx of immunosuppression Normal sensorium No focal neruo deficits Suspected bacterial meningitis
69
Factors indicate may not be safe for meningitis?
Clinical signs of impending herniation
70
Clinical features that show CT will prob be abnormal?
``` Deteriorating LOC Brainstem signs Focal neuro Recent seizures Preexisting neuro Immunocompromised state ```
71
Common pathogens that infect CSF?
``` S. Pneumo (head trauma) GBS N. Meningitis (close quarters) H. Influenza (antivaxers) L. Monocytogenes (ETOH) ``` S. Aureus/strep (post-craniotomy)
72
Never perform LP if:
Coagulopathy | Platelet < 20000/uL or INR >1.5
73
CSF eval chart
Slide 65 “treat yo self” He said to make sure you know it
74
If you suspect meningitis:
Never delay abx for LP (i know you know this but it is bolded red, underlined and mentioned several times)
75
What Empiric abx does the ed use?
18-49: ceftriaxone 2gm IV + vanc 15mg/kg IV 50+: add ampicillin 2mg IV Cepepime + vanc if recent neurosurgery
76
Bacterial meningitis with sever pcn allergy?
Replace ceptriaxone with chloramphenicol and | ampicillin with trimethoprim-sulfamethoxazole
77
What should be given before the 1st does of abx to reduce inflammation?
Dexamethasone Unless they are already on abx
78
Bacterial meningitis found in close living quarters?
N. Meningitis
79
Bacterial meningitis found in antivaxers kids?
H. Influenza | Its their kids b/c their parents made them get the vaccine so they’re g2g
80
Bacterial meningitis found in alcoholics and the elderly?
L. Monocytogenes
81
Bacterial meningitis found in penetrating Head trauma?
S. Pneumoniae
82
Bacterial meningitis found post-craniotomy?
S. Aureus | Streptococci
83
Private Joker: A day without blood:
Is like a day without sunshine

Senior - E Med (8 decks)

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