HeadacheHeadache

Benjamin Katz, MDBenjamin Katz, MD

Case StudyCase Study

28yo W c/o sudden onset 28yo W c/o sudden onset posterior headache that awoke posterior headache that awoke her from sleep. She also c/o her from sleep. She also c/o nausea/vomiting and neck nausea/vomiting and neck stiffness.stiffness.

AMPLE: no meds, nkda, no PMHx, AMPLE: no meds, nkda, no PMHx, last ate dinnerlast ate dinner

Case StudyCase Study

Vitals: HR 110 BP 180/105 RR 20 sPO2 99Vitals: HR 110 BP 180/105 RR 20 sPO2 99 AAOx3, uncomfortableAAOx3, uncomfortable PERRL, stiff neckPERRL, stiff neck RRR, CTABRRR, CTAB MAEx4, normal sensoriumMAEx4, normal sensorium

Ddx?Ddx?

Headache ClassificationHeadache ClassificationCritical SecondaryCritical Secondary

VascularVascular– Subarachnoid HemorrhageSubarachnoid Hemorrhage– Intraparenchymal Intraparenchymal

HemorrhageHemorrhage– Epidural HematomaEpidural Hematoma– Subdural HematomaSubdural Hematoma– StrokeStroke– Cavernous Sinus Cavernous Sinus

thrombosisthrombosis– Arteriovenous Arteriovenous

MalformationMalformation– Temporal ArteritisTemporal Arteritis– Carotid or Vertebral Artery Carotid or Vertebral Artery

DissectionDissection

CNS InfectionCNS Infection– MeningitisMeningitis– EncephalitisEncephalitis– Cerebral AbscessCerebral Abscess

TumorTumor Pseudotumor CerebriPseudotumor Cerebri OpthalmicOpthalmic

– GlaucomaGlaucoma– IritisIritis– Optic neuritisOptic neuritis

Drug RelatedDrug Related– NitratesNitrates– MAOI’sMAOI’s– Alcohol WithdrawalAlcohol Withdrawal

ToxicToxic– CO poisioningCO poisioning

Headache ClassificationHeadache Classification

Critical Secondary (cont)Critical Secondary (cont) EndocrineEndocrine

– PheochromocytomaPheochromocytoma MetabolicMetabolic

– HypoxiaHypoxia– HypoglycemiaHypoglycemia– HypercapniaHypercapnia– High altitude cerebral High altitude cerebral

edemaedema– PreeclampsiPreeclampsi

Reversible SecondaryReversible Secondary Non-CNS InfectionsNon-CNS Infections

– FocalFocal– SystemicSystemic– SinusitisSinusitis– OdontogenicOdontogenic– OticOtic

Drug RelatedDrug Related– Chronic Analgesia useChronic Analgesia use– MSGMSG

Post Lumbar PuncturePost Lumbar Puncture

Headache ClassificationHeadache Classification

Primary Headache SyndromesPrimary Headache Syndromes MigraineMigraine TensionTension ClusterCluster

MigraineMigraine

Onset in teensOnset in teens 5% men, 15-17% women5% men, 15-17% women Peak age 40Peak age 40 Aura: primary neuronal dysfunction: Aura: primary neuronal dysfunction:

spreading hypoactivity correlating with spreading hypoactivity correlating with reduced blood flowreduced blood flow

Headache: related to activation of sensory Headache: related to activation of sensory area, release of inflammatory peptides, area, release of inflammatory peptides, increased blood flow increased blood flow

ICHD-2 Migraine without AuraICHD-2 Migraine without Aura

5 attacks fulfilling the below5 attacks fulfilling the below Headache lasting 4-72 hoursHeadache lasting 4-72 hours At least 2 ofAt least 2 of

– Unilateral locationUnilateral location– Pulsating qualityPulsating quality– Moderate/severe pain intensistyModerate/severe pain intensisty– Aggravation by physical activityAggravation by physical activity

Associated with at least 1 ofAssociated with at least 1 of– Nausea and/or vomitingNausea and/or vomiting– Photophobia and phonophobia Photophobia and phonophobia

MigraineMigraine

Migraine with aura similar, but Migraine with aura similar, but with up to 60 minutes of any of with up to 60 minutes of any of visual scotoma, hemiparesis or visual scotoma, hemiparesis or aphasiaaphasia

Aura without migraineAura without migraine Without prior history, diagnosis of Without prior history, diagnosis of

exclusionexclusion

MigraineMigraine

TreatmentTreatment– Quiet, dark areaQuiet, dark area– IVF for nausea/vomitingIVF for nausea/vomiting– Ergot or triptansErgot or triptans– Antiemetics (reglan, phenergan, Antiemetics (reglan, phenergan,

keterolac, droperidol, compazine)keterolac, droperidol, compazine)– Maintenance (beta-blockers)Maintenance (beta-blockers)

Tension Headache (ICDH-2)Tension Headache (ICDH-2)

Infrequent episodic TTHInfrequent episodic TTH– 10+ episodes less than 1 10+ episodes less than 1

per month and 12 per year per month and 12 per year with the followingwith the following

– 30 min- 7 days30 min- 7 days– 2 of the following2 of the following

BilateralBilateral Non-pulsating pressureNon-pulsating pressure Mild/moderate intensityMild/moderate intensity Unrelated to activityUnrelated to activity

– Both of the followingBoth of the following No nausea or vomitingNo nausea or vomiting Either one of photophobia Either one of photophobia

or phonophobiaor phonophobia

Frequent TTHFrequent TTH– >1, <15 per month for 3 >1, <15 per month for 3

monthsmonths Chronic TTHChronic TTH

– >15 per month, >3months>15 per month, >3months TreatmentTreatment

– NSAIDS first lineNSAIDS first line– If severe, same as If severe, same as

migrainemigraine

Cluster HeadacheCluster Headache

Rare, 0.4% population, short without Rare, 0.4% population, short without treatment, secondary to trigeminal nerve treatment, secondary to trigeminal nerve dysfunctiondysfunction

Severe, unilateral, orbital or temporal pain Severe, unilateral, orbital or temporal pain lasting 15-180 minuteslasting 15-180 minutes

Associated with conjunctival injection, Associated with conjunctival injection, lacrimation, nasal congestion, rhinorrhea, lacrimation, nasal congestion, rhinorrhea, miosis, ptosismiosis, ptosis

Treatment: high flow O2, ergots, triptans Treatment: high flow O2, ergots, triptans (NSAIDs for maintenance)(NSAIDs for maintenance)

Red Flags for Red Flags for HeadacheHeadache Sudden Onset: SAH, AVM or mass lesionSudden Onset: SAH, AVM or mass lesion Worsening pattern: Mass, SDH, medication overuseWorsening pattern: Mass, SDH, medication overuse Headache with fever, stiff neck or rash: meningitis, Headache with fever, stiff neck or rash: meningitis,

encephalitis, lyme, systemis infection, collagen encephalitis, lyme, systemis infection, collagen vascular disease, arteritisvascular disease, arteritis

Focal neuro signs: Mass lesion, AVM, collagen vascular Focal neuro signs: Mass lesion, AVM, collagen vascular disease, CVAdisease, CVA

Trigger with cough, exertion, valsalva: SAH or massTrigger with cough, exertion, valsalva: SAH or mass Pregnancy/postpartum: sinus thrombosis, carotid Pregnancy/postpartum: sinus thrombosis, carotid

dissection, pituitary apoplexydissection, pituitary apoplexy

Red Flags ContinuedRed Flags Continued

New Headache in patient withNew Headache in patient with– Cancer: metastasisCancer: metastasis– Lyme disease: meningitisLyme disease: meningitis– HIV: opportunistic Infection, tumorHIV: opportunistic Infection, tumor

Subarachnoid HemorrhageSubarachnoid Hemorrhage

1/10,000 in U.S.1/10,000 in U.S. Young, median age 50 Young, median age 50 50% mortality at 6 months50% mortality at 6 months 50% with initially normal exam, vitals, 50% with initially normal exam, vitals,

absence of neck stiffnessabsence of neck stiffness Caused by anneurysm or AVM ruptureCaused by anneurysm or AVM rupture Diagnosis: CT detects 93% in 24hr, 80% after Diagnosis: CT detects 93% in 24hr, 80% after

24hr24hr Treatment: support ABCs, definitive Treatment: support ABCs, definitive

treatment is coiling or clippingtreatment is coiling or clipping

Intraparenchymal HemorrhageIntraparenchymal Hemorrhage

55% report headache at onset of symptoms55% report headache at onset of symptoms Suspicion if hypertension, known mass, Suspicion if hypertension, known mass,

bleeding diathesis, traumableeding diathesis, trauma Support ABCsSupport ABCs REMO protocol Hypertensive Emergency if REMO protocol Hypertensive Emergency if

SBP>220, DBP>120SBP>220, DBP>120– EKG, IV, O2, monitorEKG, IV, O2, monitor– NTG, metoprolol for chest pain, pulm edemaNTG, metoprolol for chest pain, pulm edema

Tear in middle meningeal artery or Tear in middle meningeal artery or rarely dural sinusrarely dural sinus

Direct trauma with LOC, lucid interval Direct trauma with LOC, lucid interval progressing to comaprogressing to coma

Also consider if lethargy, vomiting, Also consider if lethargy, vomiting, headache, ipsilateral dilated pupil headache, ipsilateral dilated pupil (herniation)(herniation)

Epidural HematomaEpidural Hematoma

Subdural HematomaSubdural Hematoma

Hematoma between dura mater and Hematoma between dura mater and subarachnoid due to tearing of bridging veinssubarachnoid due to tearing of bridging veins

Consider with history of falls, head trauma, Consider with history of falls, head trauma, EtOH, elderly, anticoagulationEtOH, elderly, anticoagulation

Suspect if bruise or scalp lac, lethargy, Suspect if bruise or scalp lac, lethargy, vomiting, headache, ipsilateral dilated pupilvomiting, headache, ipsilateral dilated pupil

Treatment: support ABCs, definitive Treatment: support ABCs, definitive treatment is neurosurgical evacuationtreatment is neurosurgical evacuation

StrokeStroke

80% ischemic (thrombus, embolus, 80% ischemic (thrombus, embolus, hypoperfusion)hypoperfusion)

Hemorrhagic (IPH, SAH)Hemorrhagic (IPH, SAH)– Risk if HTN, elderly, prior CVA, Asian and Blacks > Risk if HTN, elderly, prior CVA, Asian and Blacks >

whites, bleeding diathesis, vascular malformation, whites, bleeding diathesis, vascular malformation, cocaine usecocaine use

Consider thrombus if HTN, CAD, DMConsider thrombus if HTN, CAD, DM Embolus if A-fib, Valve replacement, recent Embolus if A-fib, Valve replacement, recent

MIMI

StrokeStroke

If h/o TIA with same distribution, then If h/o TIA with same distribution, then consider thrombus, if different consider thrombus, if different distribution consider embolusdistribution consider embolus

Sudden onset suggests hemorrhage or Sudden onset suggests hemorrhage or embolusembolus

Gradual onset suggests thrombus or Gradual onset suggests thrombus or hypoperfusionhypoperfusion

AssessmentAssessment

Level of ConsciousnessLevel of Consciousness Vision (fields and eye movement)Vision (fields and eye movement) Motor (strength, pronator drift)Motor (strength, pronator drift) Cerebellar function (gait, finger to nose, heel Cerebellar function (gait, finger to nose, heel

to shin)to shin) Sensation and NeglectSensation and Neglect Language Language

– Dysarthria: inability to articulateDysarthria: inability to articulate– Aphasia: defect in language processingAphasia: defect in language processing

Cranial NerveCranial Nerve

Cincinatti Prehospital Cincinatti Prehospital Stroke ScaleStroke Scale

Facial DroopFacial Droop-Normal: Both sides of face move equally well.-Normal: Both sides of face move equally well.-Abnormal: One side of face doesn’t move as well as other -Abnormal: One side of face doesn’t move as well as other side.side.

Arm DriftArm Drift-Normal: Both arms move the same -Normal: Both arms move the same oror both arms don’t both arms don’t move at all.move at all.-Abnormal: One arm doesn’t move -Abnormal: One arm doesn’t move oror one arm drifts down one arm drifts down compared to the other.compared to the other.

Speech (Ask patient to say “The sky is blue in Cincinatti”)Speech (Ask patient to say “The sky is blue in Cincinatti”)-Normal: Patient says correct words without slurring-Normal: Patient says correct words without slurring-Abnormal: Patient slurs words, says wrong words or is -Abnormal: Patient slurs words, says wrong words or is unable to speak.unable to speak.

REMO protocolREMO protocol

Draw a blood sample, check the blood Draw a blood sample, check the blood glucose level, and establish IV access.glucose level, and establish IV access.

If the patient is a diabetic, treat as per the If the patient is a diabetic, treat as per the Diabetic Emergencies Protocol. If taking an Diabetic Emergencies Protocol. If taking an opiate or analgesic medication, treat as per opiate or analgesic medication, treat as per the Overdose Protocol.the Overdose Protocol.

Monitor the EKG, CNS status and vital signs Monitor the EKG, CNS status and vital signs every 10 minutes.every 10 minutes.

Begin transportation and notify the Begin transportation and notify the destination hospital as soon as possible.destination hospital as soon as possible.

Stroke TherapyStroke Therapy

Important to identify exact Important to identify exact time patient last had time patient last had normal exam for potential normal exam for potential thrombolytic therapy (tPA)thrombolytic therapy (tPA)

Lysis if >18yo, clinical Lysis if >18yo, clinical diagnosis of ischemic CVA, diagnosis of ischemic CVA, onset less than 3 hoursonset less than 3 hours

ExclusionExclusion– minor symptomsminor symptoms– rapid improvementrapid improvement– prior ICHprior ICH– fs <50 or >400, seizurefs <50 or >400, seizure– GI/GU bleeding within 21 GI/GU bleeding within 21

daysdays– recent MIrecent MI– surgery within 14 days, surgery within 14 days,

sustained SBP>185 or sustained SBP>185 or DBP>110DBP>110

– CVA or head injury within CVA or head injury within 90 days90 days

– anticoagulant useanticoagulant use– thrombocytopeniathrombocytopenia

Temporal ArteritisTemporal Arteritis

Autoimmune Vasculitis characterized byAutoimmune Vasculitis characterized by– temporal headachetemporal headache– visual disturbance (amaurosis fugax)visual disturbance (amaurosis fugax)– claudication (masseter, temporalis tongue)claudication (masseter, temporalis tongue)– Scalp tendernessScalp tenderness– Pulsating temporal artery (absent late stage)Pulsating temporal artery (absent late stage)– Decreased visual acuityDecreased visual acuity– WeaknessWeakness– Weight lossWeight loss

Patients >50yo, women>men, 15-30 per 100,000Patients >50yo, women>men, 15-30 per 100,000 Treatment with steroids, biopsy for definitive Treatment with steroids, biopsy for definitive

diagnosis, risk for blindness if untreateddiagnosis, risk for blindness if untreated

Carotid or Vertebral DissectionCarotid or Vertebral Dissection

Characterized byCharacterized by– HeadacheHeadache– VertigoVertigo– Unilateral Horner SyndromeUnilateral Horner Syndrome

Suspect if sudden neck rotation or Suspect if sudden neck rotation or extensionextension urgent imaging and urgent imaging and neurosurgeryneurosurgery

CNS InfectionCNS Infection

Protect yourself firstProtect yourself first– Fever + headache=maskFever + headache=mask

Meningitis: inflammation of arachnoid and pia mater Meningitis: inflammation of arachnoid and pia mater caused by bacteria, virus or fungicaused by bacteria, virus or fungi– Headache, stiff neck, fever, chills, photophobia, Headache, stiff neck, fever, chills, photophobia,

confusion, phonophobia, nausea, vomiting, seizures confusion, phonophobia, nausea, vomiting, seizures (more common in children), rash, petechiae, Brudzinski (more common in children), rash, petechiae, Brudzinski or Kernig signsor Kernig signs

– Bacterial in 400 per 100,000 children, 1-2 per 100,000 Bacterial in 400 per 100,000 children, 1-2 per 100,000 adultsadults

– Long term complications of cognitive defects, epilepsy, Long term complications of cognitive defects, epilepsy, hydrocephalus, hearing losshydrocephalus, hearing loss

CNS Infection (cont)CNS Infection (cont)

Infection via subarachnoid space Infection via subarachnoid space (encapsulated organisms), also at risk if head (encapsulated organisms), also at risk if head trauma, neurosurgery, immune suppressiontrauma, neurosurgery, immune suppression

Viral meningitis-- typically less severe illness: Viral meningitis-- typically less severe illness: enterovirus, mumps, CMV, HSV, adenovirus, enterovirus, mumps, CMV, HSV, adenovirus, HIVHIV

Fungal– may be severe, consider if Fungal– may be severe, consider if immunosupressedimmunosupressed

Treatment: Support ABCs, treat for Treatment: Support ABCs, treat for shock/sepsis…definitive therapy is abxshock/sepsis…definitive therapy is abx

CNS Infections continuedCNS Infections continued

Viral Encephalitis: infection of brain Viral Encephalitis: infection of brain parenchyma (arbovirus, HSV, HVZ, EBV, CMV, parenchyma (arbovirus, HSV, HVZ, EBV, CMV, Rabies, equine encephalitis, West Nile)Rabies, equine encephalitis, West Nile)– New psychiatric sx, cognitive defect, seizures, New psychiatric sx, cognitive defect, seizures,

movement disordersmovement disorders– Treatment with antiviralsTreatment with antivirals

CNS Infections (cont)CNS Infections (cont)

Brain Abscess: uncommon infection Brain Abscess: uncommon infection extending from otitis, hemotogenous or extending from otitis, hemotogenous or instrumentationinstrumentation– Classic fever, headache, focal neuro deficit in less Classic fever, headache, focal neuro deficit in less

than one thirdthan one third– Symptoms from focal and mass effect cause Symptoms from focal and mass effect cause

delayed diagnosisdelayed diagnosis– Diagnosis with imaging, LP, +/- biopsyDiagnosis with imaging, LP, +/- biopsy– Treatment: support ABCs, antibioticsTreatment: support ABCs, antibiotics

Tumor: 70% with headache, classically worse in the Tumor: 70% with headache, classically worse in the morning, positional, nausea and vomitingmorning, positional, nausea and vomiting

Pseudotumor cerebri: headache worse with Pseudotumor cerebri: headache worse with awakening, valsalva, cough, bendingawakening, valsalva, cough, bending– Signs of increased ICP: papilledema, CN VI palsy, diploia, Signs of increased ICP: papilledema, CN VI palsy, diploia,

visual deficits, tinnitusvisual deficits, tinnitus– Linked with OCP use, vit A, tetracycline use, thyroid Linked with OCP use, vit A, tetracycline use, thyroid

disordersdisorders– Diagnosed with CT for hydrocephalus, LP for high Diagnosed with CT for hydrocephalus, LP for high

opening pressureopening pressure– Treatment diuretics, repeat LP, CSF shunt or optic nerve Treatment diuretics, repeat LP, CSF shunt or optic nerve

sheath fenestrationsheath fenestration

OpthalmicOpthalmic

GlaucomaGlaucoma– Acute angle closure: obstruction of aqueous humor Acute angle closure: obstruction of aqueous humor

outflow leading to increased intraocular pressure outflow leading to increased intraocular pressure and possible blindnessand possible blindness

– Sudden onset painful vision loss associated with Sudden onset painful vision loss associated with headache, nausea, vomiting, somnolenceheadache, nausea, vomiting, somnolence

– Exam with decreased vision, conjunctival injection, Exam with decreased vision, conjunctival injection, hazy cornea, fixed/mid-position or dilated hazy cornea, fixed/mid-position or dilated unreactive pupilunreactive pupil

– Needs emergent opthomology referral, eye gttsNeeds emergent opthomology referral, eye gtts

OpthalmicOpthalmic

Iritis: inflamation of the IrisIritis: inflamation of the Iris– Risk if sarcoid, STDs, collagen vascular dzRisk if sarcoid, STDs, collagen vascular dz– Blurred vision, deep eye pain, photophobia, red Blurred vision, deep eye pain, photophobia, red

eyeeye– Exam with conjunctival injection, cell and flareExam with conjunctival injection, cell and flare– Optho referral, topical steroids, cycloplegic dropsOptho referral, topical steroids, cycloplegic drops

Optic Neuritis: painful vision loss due to Optic Neuritis: painful vision loss due to inflammation of optic nerveinflammation of optic nerve– Consult with opthomology regarding iv steroidsConsult with opthomology regarding iv steroids

Drug Related Drug Related HeadacheHeadache Nitrates: symptomatic hypotension, Nitrates: symptomatic hypotension,

hypoperfusionhypoperfusion MAOIs: orthostatic hypotension, but can have MAOIs: orthostatic hypotension, but can have

hypertensive crisis when taken with hypertensive crisis when taken with sympathomimetic amines, l-dopa, narcotics sympathomimetic amines, l-dopa, narcotics or tyramine containing foods (cheese)or tyramine containing foods (cheese)

Alcohol withdrawal: treat with Alcohol withdrawal: treat with benzodiazepinesbenzodiazepines

ToxicToxic

Carbon Monoxide PoisoningCarbon Monoxide Poisoning– CO competes with O2 for Hgb binding with 250x CO competes with O2 for Hgb binding with 250x

affinity affinity – Suspect with confined space fire, car engine left Suspect with confined space fire, car engine left

on, several household members sick at same timeon, several household members sick at same time– Half life 320 min @ RA, 82 min @ 100 %NRB, 23 Half life 320 min @ RA, 82 min @ 100 %NRB, 23

min @ 3 atm HBOmin @ 3 atm HBO– Headache, nausea, vomiting, malaise, chest pain, Headache, nausea, vomiting, malaise, chest pain,

weaknes, apathy, cherry red skin, abnormal weaknes, apathy, cherry red skin, abnormal reflexes, altered mental statusreflexes, altered mental status

– Treat with O2, consider transfer to hyperbarric Treat with O2, consider transfer to hyperbarric chamberchamber

MetabolicMetabolic

HypoxiaHypoxia HypoglycemiaHypoglycemia HypercapniaHypercapnia High Altitude Cerebral EdemaHigh Altitude Cerebral Edema

– Due to acute hypoxia from rapid ascentDue to acute hypoxia from rapid ascent– Higher risk if pulm dz, EtOH/drug use, dehydrationHigher risk if pulm dz, EtOH/drug use, dehydration– Headache, anorexia, nausea, vomiting, weakness, Headache, anorexia, nausea, vomiting, weakness,

altered mental statusaltered mental status seizure/coma/death seizure/coma/death– Treat with immediate descent, 100%O2, Dexamethasone Treat with immediate descent, 100%O2, Dexamethasone

+/- HBO+/- HBO Preeclampsia: after 20Preeclampsia: after 20thth week of pregnancy—BP week of pregnancy—BP

>160/110, proteinuria, peripheral edema>160/110, proteinuria, peripheral edema– May progress to eclampsia (above + seizures)May progress to eclampsia (above + seizures)– Definitive treatment is delivery, may use hydralazine for Definitive treatment is delivery, may use hydralazine for

HTN, magnessium sulfate for seizureHTN, magnessium sulfate for seizure

Non-CNS InfectionNon-CNS Infection

Systemic– viral syndromes, bacteremia, fever Systemic– viral syndromes, bacteremia, fever may often cause generalized headachemay often cause generalized headache– Antipyretic for fever, definitive treatment for Antipyretic for fever, definitive treatment for

source of infectionsource of infection Sinusitis– inflammation of ethmoid, frontal, Sinusitis– inflammation of ethmoid, frontal,

sphenoid or maxillary sinussphenoid or maxillary sinus– Fever, malaise, anosmia, headache and toothache, Fever, malaise, anosmia, headache and toothache,

purulent discharge, postnasal drip, sore throat, purulent discharge, postnasal drip, sore throat, facial pain/pressurefacial pain/pressure

– Antibiotics and nasal decongestants, antipyretics Antibiotics and nasal decongestants, antipyretics for fever and analgesiafor fever and analgesia

Non-CNS InfectionsNon-CNS Infections

Dental Infections—Caries and/or periapical abscessDental Infections—Caries and/or periapical abscess– Toothache, jaw pain, earache, jaw pain, tooth tender to Toothache, jaw pain, earache, jaw pain, tooth tender to

percussionpercussion– Treatment involves covering exposed tooth, analgesia, Treatment involves covering exposed tooth, analgesia,

abscess drainage if appropriateabscess drainage if appropriate Ear InfectionsEar Infections

– Otitis Media– middle ear infection with ear pain/fullness, Otitis Media– middle ear infection with ear pain/fullness, decreased hearing, vertigo, fever. Treat with antibiotics, decreased hearing, vertigo, fever. Treat with antibiotics, antipyreticsantipyretics

– Otitis Externa– External Ear infection with itching, Otitis Externa– External Ear infection with itching, decreased hearing, fever, tender external ear. Treated decreased hearing, fever, tender external ear. Treated with antibiotic drops. Caution if diabetic for malignant with antibiotic drops. Caution if diabetic for malignant OEOE

Post Lumbar PuncturePost Lumbar Puncture

Headache is secondary to loss of CSFHeadache is secondary to loss of CSF– Persistent headache due to CSF leak after LPPersistent headache due to CSF leak after LP– Definitive Treatment is Blood PatchDefinitive Treatment is Blood Patch– Keep patient supine +/- Trendellenberg Keep patient supine +/- Trendellenberg

CasesCases

56 yo W with throbbing right 56 yo W with throbbing right sided headache, “darkened” sided headache, “darkened” vision on the right vision on the right

CasesCases

21yo W with throbbing left sided 21yo W with throbbing left sided headache for 1 day preceded by headache for 1 day preceded by seeing bright lightsseeing bright lights

CasesCases

45yo HIV+ M c/o several day h/o 45yo HIV+ M c/o several day h/o headache, blurred vision, vertigo, headache, blurred vision, vertigo, nausea and vomitingnausea and vomiting

CasesCases

65yo M w/ CAD and HTN with 65yo M w/ CAD and HTN with acute onset of dysarthria, right acute onset of dysarthria, right sided weaknesssided weakness

CasesCases

22yo M w/ fever, stiff neck and 22yo M w/ fever, stiff neck and

Questions?Questions?