Headache & Facial PainChpt. 227

Jen Donze D.O.Prepared by Brian Holod D.O.11/10/05

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Headache

• HA represents up to 4% ED visits

• Most ED pts. with benign primary HA, but up to 3.8% with serious or secondary pathology

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HA- ED Objectives

1. To appropriately select patients for emergency investigation and treatment of suspected critical secondary HA causes

2. To diagnose and effectively treat patients with generally benign and reversible secondary HA causes

3. To provide effective treatment for primary HA syndromes

4. To provide appropriate disposition and follow-up for all discharged pts

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ACEP HA Categories

I. Critical 2° causes requiring emergent classification and Tx (SAH, meningitis, brain tumor with ↑ ICP)

II. Critical 2° causes not necessarily requiring emergent Dx or Tx (brain tumor w/o ↑ ICP)

III. Generally benign and reversible 2° causes (sinusitis, HTN, post-LP)

IV. 1° HA syndromes (migraine, tension, cluster)

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History

Pattern- 1st severe HA, worst ever, worsening over several days or significantly different from prior HA’s

Onset- sudden onset especially w/ exertion (cough, defecation)

Location- unilateral, bilateral, occipitolnuchal

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History

• Associated symptoms- syncope, altered LOC, confusion, neck pain/stiffness, visual Δ’s, fever, seizure, jaw claudication

• Other- medications, trauma, toxic exposures

• Family Hx- migraines or SAH

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Physical Examination

• General appearance and vitals• Fever- infectious• HTN- ? HTN

urgerncy/emergency• HEENT-sinuses, temporal

arteries, TMJ, dentition, IOP, visual field defects, papilledema

• Neuro- gait, MS, Cranial nerves, motor/sensory exam, reflexes and cerebellar testing

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Subarachnoid Hemorrhage

• Annual incidence 1/10,000 year in U.S.

• High mortality; 50% die within 6mo.

• ½ pts. w/ nml neuro exam @ presentation

• HA severe w/ sudden onset• HA most commonly

occiptonuchal

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Subarachnoid Hemorrhage

• CT head 93% sensitive within 24h, ↓ ~80% after 24h

• LP mandatory if neg CT and suspect SAH

• Xanthochromia gold standard Dx

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Hunt and Hess Classification of Subarachnoid HemorrhageGrade I Asymptomatic of minimal headache and slight nuchal rigidity.Grade II Moderate to severe headache, nuchal rigidity, no neurologica deficit other thancranial nerve palsy.Grade III Drowsiness, confusion, or mild focal deficit.Grade IV Stupor, moderate to severe hemiparesis, possible early decerebrate ridigity andvegetative disturbance.Grade V Deep coma, decerebrate ridigity, moribund appearance.

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Subarachnoid Hemorrhage

• Neurosurgical consultation• Nimodipine 60mg PO q6h• Prophylactic Phenytoin

loading• Antiemetics

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Meningitis

• Usually w/ fever & meningismus

• HA may be severe w/ rapid onset

• Opportunistic infxn (cryptococcal) in immunocompromised may have more insidious onset

• LP mandatory if any suspicion

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Intraparenchymal Hemorrhage & Cerebral

Ischemia• 55% pts w/ intraparenchymal

hemorrhage have HA @ onset symptoms

• 17% ischemic stroke w/ HA• 6% TIA w/ HA• Other neurologic signs and

symptoms will be present in most of these pts.

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Subdural Hematoma

• Hx remote trauma• Be careful in high risk pts

(elderly, anticoagulants, alcoholics)

• If suspected w/ nml non-contrast CT then consider contrast enhanced CT or MRI

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Brain Tumor

• Up to 70% pts w/ brain tumor have HA @ time of Dx & only 8% have abnml findings neuro exam

• May be unilateral or bilateral, intermittent or continuous

• Classically worse in A.M. & assoc w/ nausea & vomiting

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Temporal Arteritis

• Almost exclusively in pts >50 y/o• Incidence 15-30/100,000 >50 y/o• More common in women• HA 60-90% pts• Severe, throbbing HA in

frontotemporal region• Assoc. w/ jaw claudication, PMR,

vision loss 2°optic neuritis

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Temporal Arteritis

• Dx- age >50, new-onset localized HA, temporal artery tenderness, ESR >50, abnml temporal artery biopsy

• Tx- Prednisone 40-60mg PO QD when suspected, urgent referral for definitive Dx and follow-up

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Opthalmic Disorders

• Glaucoma, optic neuritis, iritis may present w/ HA

• Usually can be distinguished by careful Hx, eye exam & IOP measurement when indicated

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Hypertension

• Higher diastolic pressures assoc w/ more severe HA’s

• HTN may be sign of other cause HA (stroke, preeclampsia, pheochromocytoma) or 2° pain & anxiety from primary HA

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Sinusitis

• Assoc w/ facial pain & HA depending on sinuses involved

• HA can vary w/ head position• Purulent nasal discharge,

maxillary toothache, abnml transillumination, poor response decongestants

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Drug, Toxins & Metabolic HA

• Nitrates, MAOI’s, chronic analgesic use

• MSG or CO• Hypoxia, hypercapnia &

hypoglycemia• EtOH withdrawl• Dx w/ Hx and appropriate

tests

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Pseudotumor Cerebri

• Young, obese pts w/ long standing HA

• N/V and visual Δ’s may be present

• Linked to OCP, Vit A, thyroid disorders and tetracycline

• Papilledema, nml LOC, nml CT & marked ↑ CSF pressure on LP

• Tx-acetazolamide and steroids, repeat LP’s or shunt if meds fail

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Internal Carotid/Vertebral Artery Dissection

• Rare, but frequently assoc w/HA

• Spontaneous or 2° trauma• Most eventually develop

neuro symptoms• Dx usually by angiography,

duplex scan or MRI• SAH may be caused by

dissection & must be R/O prior anticoagulation

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Post LP HA

• 10-36% pts who undergo LP have HA within 24-48h

• D/T persistent CSF leak from dura

• Minimize w/ small bore or noncutting needles

• Tx w/ analgesics, IVF, IV caffeine or blood patch

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Primary HA Syndromes

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Migraine

• Common, onset early teens• Prevalance 5% male, 16%

female• Primary response of brain

tissue to a trigger resulting in dysfunction of pathways that modulate sensory input w/ 2° disorder of vasculature

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Migraine

• Most w/o aura• Slow onset, lasts 4-72h• Typically unilateral and

pulsating, worse w/ physical activity

• N/V, photo/phonophobia frequently present

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Migraine

• Visual aura most common• Other auras include aphasia,

hemipariesis, hemiparesthesia, other speech difficulties or brainstem symptoms

• Migraine prodromes-lethargy, hyperactivity, yawning, depression, food craving, polyuria or fluid retention

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Migraine-TX• DHE- 5HT1B/1D agonist w/

antiemetic 1st line• Triptans- more selective 5HT1D

agonists cause less N/V• Metoclopramide, chlorpromazine,

prochlorperazine, ketorolac and droperidol have been effective in RCT’s

• Place in dark, quiet room and rehydrate pt.

• Opioids less effective than other agents

• Dexamethazone effective reducing rate recurrent migraine after std Tx

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Migraine

• Migraines generally improve w/ pregnancy, try nonpharmacologic therapy (rest, ice) first then consider acetaminophen or metoclopramide

• Preventive therapy by avoiding triggers and pharmacologically in collaboration w/PCP or neuro

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Tension HA

• Thought 2° extracranial muscle tension, although unproven

• May share common pathway w/ migraine

• Bilateral, non-pulsating, not worse w/ exertion & no N/V

• Tx w/ simple analgesics or NSAIDS

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Cluster HA

• Rare, prev 0.4% population• Short lived w/o Tx• More common in men,

usually after 20 y/o• Dysfuction trigeminal nerve

suspected• Response to 5HT agonists

suggests common mechanism w/ migraines

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Cluster HA

• Severe unilateral orbital, supraorbital or temporal pain

• Pts. Can rarely lie still• Associated w/ conjuctival

injection, lacrimation, nasal congestion, rhinorrhea, facial swelling, miosis or ptosis

• Occur in clusters over weeks and may then remit for years

• High flow O2, DHE & sumitriptan

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Temporomandibular Disorder

• Dysfuction TMJ, surrounding muscles or ligaments

• TMJ noise and pain w/ movement, limited jaw movement, jaw locking, bruxism and tongue, lip or cheek biting

• Multidisiplinary approach• Radiographs little help• NSAIDs initial Tx

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Trigeminal Neuralgia

• Severe unilateral pain in trigeminal nerve distribution lasting seconds

• Nml neuro exam• No pain between paroxysms• Carbamazepine effective Tx,

Dx unlikely if Tx fails• Intractable symptoms

despite medical Tx refer neurosurgeon

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Questions

1. All are causes of primary HA syndromes except?

a) Migraineb) Brain Tumorc) Tensiond) Cluster

Answer: b

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Questions

2. A normal non-contrast CT excludes the possibility of SAH?

True/False

False- Up to 12% pts may have SAH & nml CT exam

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Questions

3. All are characteristics of HA with potentially severe underlying pathology except?

a) Sudden onsetb) Papilledemac) Relief with Tylenold) Change in Mental Status

Answer: C

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Questions

4. In a patient with suspected temporal arteritis, the most appropriate ED management would be?

a) Refer for temporal artery biopsy as outpatient

b) Discharge with narcotic medication for pain

c) Rest in dark room and take OTC analgesics

d) Immediate Prednisone therapy

Answer: D

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Questions

5. Benign, reversible secondary HA syndromes include all of the following except?

a) Meningitisb) Sinusitisc) Post-LP HAd) Chronic analgesic use HA

Answer: A