Lecture 4: Headaches in the ED Flashcards
1
Q
Red Flags in History for ED pt presenting with HA
A
- Age < 5 or > 50 with new/worsening HA
- Sudden onset thunderclap (Cerebral aneurysm)
- Sudden onset with exertion (SAH, Arterial dissection)
- Fever with HA onset (meningitis)
- Different quality HA
- Usage of bloodthinners (risk of hemorrhage)
- Recent ABX use (may lessen clinical presentation)
Sudden varies, dependent on condition.
Sudden for thunderclap = seconds!
2
Q
What is considered analgesic overuse when it comes to HAs?
A
> 10 times a month = risk of rebound HA
3
Q
What illegal substances can increase risk of hemorrhage in HAs?
A
- Cocaine
- Amphetamine
- Methamphetamine
4
Q
What combination on PE might suggest meningitis?
A
- HA (esp if it persists despite control of fever)
- Fever
- Neck stiffness
- AMS
5
Q
What fundoscopic finding suggests increased ICP?
A
Optic desk papilledema = increase ICP
Acute angle closure glaucoma
6
Q
What might meningismus suggest?
A
- Infection
- Hemorrhage
7
Q
What should ALWAYS BE PERFORMED for a patient with HA?
A
Neurologic exam
Must do CN exam, motor, sensation, gait, DTRs
8
Q
What associated conditions are concerning with presence of HA?
A
- Pregnancy
- SLE
- Behcets
- Vasculitis
- Sarcoidosis
- Cancer
Immunosuppressed patients. Consider infection.
9
Q
What labs are recommended for a high risk pt presenting with HA?
A
- CBC w/ blood cultures (suspected infection)
- CMP
- Coag panel (suspected bleed or need for LP)
- ESR/CRP (temporal arteritis)
- hCG
10
Q
When is non-con head CT indicated for HA eval?
A
- Abnormal neurologic exam
- New/severe HA of sudden onset
- HIV+ with new HA
- Concerned for increased ICP in pt requiring an LP
11
Q
Indication for LP in evaluation of ED pt with HA
A
- Meningitis
- Encephalitis
- Intracranial hypotension
- Pseudotumor cerebri
- SAH (if CT was neg but still sus)
CT scan is reliable within 6 hrs of hemorrhage for SAH
12
Q
MCC of people presenting to ED with HA
A
Primary HAs: Migraine, cluster, tension
13
Q
Migraine presentation
A
- Slow onset, over 72h usually
- MC aura types are lightheaded or visual changes
- unilateral throbbing/pulsatile
- Worsens with physical activity
- N/V, photophobia, phonophobia
MC overall
14
Q
Migraine Management in the ED
A
- Analgesic + antiemetic + antihistamine = first line
- Ketorolac + prochlorperazine + diphenhydramine
- Dexamethasone used to reduce risk of recurrence
OK to use metoclopramide too instead.
15
Q
When are triptans indicated in migraine management in ED?
A
- No usage prior to arrival.
- CI in pregnancy, CAD, uncontrolled HTN, or CVD
Causes vasoconstriction. Sumatriptan SC or IN.
16
Q
When are ergot derivatives indicated in migraine management?
A
- Requires pretx with antiemetic +/- antihistamine
- CI in HTN, IHD, PAD, Pregnancy
DHE4 + metoclopramide +/- diphenhydramine
17
Q
Management of a pregnant pt with migraine in the ED
A
- Acetaminophen, Opioids, metoclopramide, corticosteroids
- NSAIDs ok in 1st and 2nd trimesters.
- CI: Triptans, ergotamines, caffeine (Excedrin)
18
Q
Prevention of migraines post ED tx
A
- Sumatriptan
- Midrin
Take triptan as soon as pain begins.
19
Q
Presentation of cluster HA in the ED
A
- unilateral, excruciating pain
- Pain lasts 12min-180min w/o tx
- Ipsilateral symptoms: lacrimation, conjunctival infection, nasal congestion, edema, sweating
- Recurring daily for > week and remitting for 4+ weeks
- Can be precipitated by ETOH or vasodilators
- Normal neuro
Often located periorbital.
20
Q
Management of cluster HA in ED
A
- High flow O2 12LPM via NRB
- Sumatriptan if O2 doesn’t resolve
- Last resort: IN lidocaine, oral ergotamine/caffeine, IV DHE 45
21
Q
Transitional therapy for cluster HA in ED
A
- Tapered prednisone over 2wks
- Naratriptan BID
- Ergotamine QHS or BID
F/u with neurology afterwards.
22
Q
Presentation of tension HA in ED
A
- Gradual onset
- Diffuse, band-like, vise-like (occipital/frontal)
- Duration: Hours to days
- Mild nausea and photophobia
- Prior: Tension, stress, fatigue
- Normal neuro
23
Q
Management of tension HA in ED
A
- NSAIDs/non-opioid analgesic +/- caffeine +/- antiemetic/sedative
- Muscle relaxant if muscle tension noted (only take at night due to sedative effects)
PCP f/u
Ketorolac + compazine/reglan + diphenhydramine
Excedrin OTC for OP use
Take medication as soon as you start feeling pain!
24
Q
Presentation of brain tumor
A
- Mild HA, deep aching in nature
- Early on: no focal neuro deficits, HA increasing in frequency/duration CLASSIC
- Later: constant pain, focal neuro deficits
- Worsens upon awakening and with valsalva
25
What can confirm dx of brain tumor in the ED?
**CT scan with con** or MRI if available
26
Management of brain tumor in ED
* Neurosurg consult for large, symptomatic, signs of increased ICP, or impending herniation
* IV glucorticoids (dexamethasone) to reduce cerebral edema
* **secondary** Antiseizure agent (keppra, topa, lamo, VPA, lacosamide)
* Secure airway if herniation is impending on imaging
| Only use secondary if a seizure occurs.
27
Presentation of post-trauma HA/post concussive syndrome
* **Hx of Head injury**
* Variable onset of pain
* Non-specific HA (similar to tension or migraine)
* Fatigue, dizziness, vertigo, insomnia, personality changes, etc
27
Evaluation of post-traumatic headache
**CT w/o con** if no previous evaluation yet
28
Management of post-traumatic HA
* Simple = d/c home and f/u with PCP. Usage of nonopiate analgesics or antiemetics
* Avoid activity that could lead to second injury or worsen symptoms.
* Need to gradually return to baseline physical activity
29
Main characteristics of Idiopathic intracranial HTN/pseudotumor cerebri
Syndrome characterized by
* Papilledema
* Increased ICP
* Normal/small-sized ventricles on imaging
30
Presentation of Idiopathic Intracranial HTN
1. **HEADACHE**
2. Transient visual obscurations
3. Pulsatile tinnitus
4. Scotoma/scintillations
5. Back pain
6. Retrobulbar pain
7. Diplopia
8. Sustained visual loss, which can become permanent
| In order of frequency!
## Footnote
PE will show papilledema, visual field loss, and 6th CN palsy.
31
How does 6th CN palsy present?
Loss of lateral gaze
32
Dx of Idiopathic Intracranial HTN
* CT scan of brain w/o con = normal
* **LP with opening presure > 25cm h2o for adults or 28 in children.**
* LP with normal CSF
| Must educate pt to avoid valsalva during LP opening
## Footnote
**Opening pressure must be performed in lateral decubitus with knees extended!**
33
Managment of Idiopathic Intracranial HTN
1. **Preserve vision**
2. Remove CSF until opening pressure = 10-20 cm H2O. 1mL CSF = 1 cm H2O
3. Oral acetazolamide +/- thiazide
4. If a new Dx = admit
5. If old Dx = consult neuro
| Acetazolamide = reduction of CSF production
## Footnote
Avoid serial LPs
34
Presentation of PDPH/intracranial HYPOtension
* **Recent hx of LP** (MC etiology)
* 24-48h of post-LP
* Bifrontal/occipital
* **Worse in upright position, improving in supine**
* Auditory, visual, N/V, neck stiffness, LBP, vertigo, dizziness
| Leakage of CSF and absorption into surrounding tissue.
35
Dx of post-dural puncture HA (PDPH)/intracranial hypotension
* Avoid repeating LP.
* If LP is repeated, opening pressure will be very low at < 6cm H2O
* No need for MRI/CT, but it will show **diffuse enhancement of the meninges**
| WikEM says dx is clinical if it was post-LP.
## Footnote
Spontaneous intracranial hypotension needs LP or MRI/CT
36
Management of PDPH
* **Recumbent position for a day**
* IVF
* Non-opiate analgesics +/- **caffeine**
* Consult anesthesiology for need for epidural blood patch
## Footnote
Injection of pt's blood over opening to clot.
37
MC ways for brain abscess to form
* Hematogenous spread
* Direct contiguous infection
* Direct seeding by neurosurgery
* Penetrating trauma
38
Presentation of brain abscess
* HA
* Focal neurologic deficits
* Fever
* Seizure
* S/S of increased ICP
| Similar to meningitis?
39
Workup for a Brain abscess
1. **CT or MRI brain w/ con is diagnostic**
2. CBC (leukocytosis)
3. CMP (end organ function)
4. CRP/ESR elevated in 2/3 of pts
5. Blood cultures 2x before first abx
| **Avoid LP**
40
Management of brain abscess
1. Odontogenic = PCN G (rocephin + metro)
2. Post-neuro procedure: vanco + cefatzidime
3. Anything else: Cefotaxmine + metro
4. **Steroids only if significant peri-abscess edema w/ associated mass effect and increased ICP**
5. Need neurosurg to consider aspiration
| Based on suspected source
## Footnote
Steroids will dissolve abscess wall!!!!!!!!
41
MC location for spinal epidural abscess
* Thoracic
* Lumbar
42
MCC of spinal epidural abscess
**Hematogenous spread from soft tissue (MC S. aureus)**, urine, or respiratory
43
Risk factors for spinal epidural abscess
* IVDU
* Immunosuppressed
* Prior spinal procedure
44
Presentation of spinal epidural abscess
* Early: Back pain, fever, spinal tenderness
* Later: Radicular pain, hyperreflexia, nuchal rigidity
* **Progressive neuro deficits (Cauda Equina)**
45
Cauda Equina Mnemonic
* Saddle anesthesia
* Pain (lower back/lower limbs)
* Incontinence (stool/urine)
* Numbness (groin/legs)
* Emergency (surgery)
| SPINE
## Footnote
Check rectal tone, motor weakness, and perineal sensation
46
Dx of spinal epidural abscess
* **MRI w/ con of spine** (CT if no MRI available)
* CBC (Leukocytosis in most)
* Elevated ESR/CRP
* Blood cultures
| LP is CI if epidural abscess is suspected
47
Management of spinal epidural abscess
* Empiric ABX: Vanco + ceftazidime (same as post-neuro brain abscess)
* Consult neurosurg
