A Few Random Thoughts About Headaches

CCFP (EM) RoundsDec 17th, 2009

Ian Walker

What Will We Be Talking About?

• Migraine• SAH Workup• Significant CT negative HA’s• Trigeminal Neuralgia• Cluster Headache

Migraine

• Define It!!• Treatment

Options?

Worrisome Features for SAH

• Thunderclap• Exertional or Coital• Vascular Risk Factors• Family History• Meningismus• Altered LOC

The LP Controversies

• When?• What constitutes

positive?• Checking for Xantho

Differential?

A Case

• This Woman• Waxing and waning

headache for 4 days• Diplopia yesterday,

none now• Worse supine• Nausea• No history of same• Slight weakness on L

Dural Sinus Thrombosis

• Think elevated ICP• Think DVT of the brain• Think CT Venogram• Think LP• Think about it

What Should Make You Think About It?

• Manipulation• Trauma (MVC, etc)• Neuro findings• Horner’s• Cerebellar Findings

Another Case

• This Patient• 1 week of headache• Worse in am• Worse laying down• Intermittent Visual

blurring

• What’s The Best Test?

Does this 48 year old Man have GCA?

Cluster Headache

• Severe, unilateral• Rhinorhea and lacrimation• Headaches “cluster” temporally• O2, lidocaine, verapamil, pre-gabalin• Great patient for a neurologist

PUTTING IT ALL TOGETHER