Headache Benjamin Katz, MD. Case Study 28yo W c/o sudden onset posterior headache that awoke her...

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Transcript of Headache Benjamin Katz, MD. Case Study 28yo W c/o sudden onset posterior headache that awoke her...

  • HeadacheBenjamin Katz, MD

  • Case Study28yo W c/o sudden onset posterior headache that awoke her from sleep. She also c/o nausea/vomiting and neck stiffness.AMPLE: no meds, nkda, no PMHx, last ate dinner

  • Case StudyVitals: HR 110 BP 180/105 RR 20 sPO2 99AAOx3, uncomfortablePERRL, stiff neckRRR, CTABMAEx4, normal sensorium

    Ddx?

  • Headache ClassificationCritical SecondaryVascularSubarachnoid HemorrhageIntraparenchymal HemorrhageEpidural HematomaSubdural HematomaStrokeCavernous Sinus thrombosisArteriovenous MalformationTemporal ArteritisCarotid or Vertebral Artery Dissection

    CNS InfectionMeningitisEncephalitisCerebral AbscessTumorPseudotumor CerebriOpthalmicGlaucomaIritisOptic neuritisDrug RelatedNitratesMAOIsAlcohol WithdrawalToxicCO poisioning

  • Headache ClassificationCritical Secondary (cont)EndocrinePheochromocytomaMetabolicHypoxiaHypoglycemiaHypercapniaHigh altitude cerebral edemaPreeclampsi

    Reversible SecondaryNon-CNS InfectionsFocalSystemicSinusitisOdontogenicOticDrug RelatedChronic Analgesia useMSGPost Lumbar Puncture

  • Headache ClassificationPrimary Headache SyndromesMigraineTensionCluster

  • MigraineOnset in teens5% men, 15-17% womenPeak age 40Aura: primary neuronal dysfunction: spreading hypoactivity correlating with reduced blood flowHeadache: related to activation of sensory area, release of inflammatory peptides, increased blood flow

  • ICHD-2 Migraine without Aura5 attacks fulfilling the belowHeadache lasting 4-72 hoursAt least 2 ofUnilateral locationPulsating qualityModerate/severe pain intensistyAggravation by physical activityAssociated with at least 1 ofNausea and/or vomitingPhotophobia and phonophobia

  • MigraineMigraine with aura similar, but with up to 60 minutes of any of visual scotoma, hemiparesis or aphasiaAura without migraineWithout prior history, diagnosis of exclusion

  • MigraineTreatmentQuiet, dark areaIVF for nausea/vomitingErgot or triptansAntiemetics (reglan, phenergan, keterolac, droperidol, compazine)Maintenance (beta-blockers)

  • Tension Headache (ICDH-2)Infrequent episodic TTH10+ episodes less than 1 per month and 12 per year with the following30 min- 7 days2 of the followingBilateralNon-pulsating pressureMild/moderate intensityUnrelated to activityBoth of the followingNo nausea or vomitingEither one of photophobia or phonophobiaFrequent TTH>1, 15 per month, >3monthsTreatmentNSAIDS first lineIf severe, same as migraine

  • Cluster HeadacheRare, 0.4% population, short without treatment, secondary to trigeminal nerve dysfunctionSevere, unilateral, orbital or temporal pain lasting 15-180 minutesAssociated with conjunctival injection, lacrimation, nasal congestion, rhinorrhea, miosis, ptosisTreatment: high flow O2, ergots, triptans (NSAIDs for maintenance)

  • Red Flags for HeadacheSudden Onset: SAH, AVM or mass lesionWorsening pattern: Mass, SDH, medication overuseHeadache with fever, stiff neck or rash: meningitis, encephalitis, lyme, systemis infection, collagen vascular disease, arteritisFocal neuro signs: Mass lesion, AVM, collagen vascular disease, CVATrigger with cough, exertion, valsalva: SAH or massPregnancy/postpartum: sinus thrombosis, carotid dissection, pituitary apoplexy

  • Red Flags ContinuedNew Headache in patient withCancer: metastasisLyme disease: meningitisHIV: opportunistic Infection, tumor

  • Subarachnoid Hemorrhage1/10,000 in U.S.Young, median age 50 50% mortality at 6 months50% with initially normal exam, vitals, absence of neck stiffnessCaused by anneurysm or AVM ruptureDiagnosis: CT detects 93% in 24hr, 80% after 24hrTreatment: support ABCs, definitive treatment is coiling or clipping

  • Intraparenchymal Hemorrhage55% report headache at onset of symptomsSuspicion if hypertension, known mass, bleeding diathesis, traumaSupport ABCsREMO protocol Hypertensive Emergency if SBP>220, DBP>120EKG, IV, O2, monitorNTG, metoprolol for chest pain, pulm edema

  • Epidural HematomaTear in middle meningeal artery or rarely dural sinusDirect trauma with LOC, lucid interval progressing to comaAlso consider if lethargy, vomiting, headache, ipsilateral dilated pupil (herniation)

  • Subdural HematomaHematoma between dura mater and subarachnoid due to tearing of bridging veinsConsider with history of falls, head trauma, EtOH, elderly, anticoagulationSuspect if bruise or scalp lac, lethargy, vomiting, headache, ipsilateral dilated pupilTreatment: support ABCs, definitive treatment is neurosurgical evacuation

  • Stroke80% ischemic (thrombus, embolus, hypoperfusion)Hemorrhagic (IPH, SAH)Risk if HTN, elderly, prior CVA, Asian and Blacks > whites, bleeding diathesis, vascular malformation, cocaine useConsider thrombus if HTN, CAD, DMEmbolus if A-fib, Valve replacement, recent MI

  • StrokeIf h/o TIA with same distribution, then consider thrombus, if different distribution consider embolusSudden onset suggests hemorrhage or embolusGradual onset suggests thrombus or hypoperfusion

  • AssessmentLevel of ConsciousnessVision (fields and eye movement)Motor (strength, pronator drift)Cerebellar function (gait, finger to nose, heel to shin)Sensation and NeglectLanguage Dysarthria: inability to articulateAphasia: defect in language processingCranial Nerve

  • Cincinatti Prehospital Stroke ScaleFacial Droop-Normal: Both sides of face move equally well.-Abnormal: One side of face doesnt move as well as other side.Arm Drift-Normal: Both arms move the same or both arms dont move at all.-Abnormal: One arm doesnt move or one arm drifts down compared to the other.Speech (Ask patient to say The sky is blue in Cincinatti)-Normal: Patient says correct words without slurring-Abnormal: Patient slurs words, says wrong words or is unable to speak.

  • REMO protocolDraw a blood sample, check the blood glucose level, and establish IV access.If the patient is a diabetic, treat as per the Diabetic Emergencies Protocol. If taking an opiate or analgesic medication, treat as per the Overdose Protocol.Monitor the EKG, CNS status and vital signs every 10 minutes.Begin transportation and notify the destination hospital as soon as possible.

  • Stroke TherapyImportant to identify exact time patient last had normal exam for potential thrombolytic therapy (tPA)Lysis if >18yo, clinical diagnosis of ischemic CVA, onset less than 3 hours

    Exclusionminor symptomsrapid improvementprior ICHfs 400, seizureGI/GU bleeding within 21 daysrecent MIsurgery within 14 days, sustained SBP>185 or DBP>110CVA or head injury within 90 daysanticoagulant usethrombocytopenia

  • Temporal ArteritisAutoimmune Vasculitis characterized by temporal headachevisual disturbance (amaurosis fugax)claudication (masseter, temporalis tongue)Scalp tendernessPulsating temporal artery (absent late stage)Decreased visual acuityWeaknessWeight lossPatients >50yo, women>men, 15-30 per 100,000Treatment with steroids, biopsy for definitive diagnosis, risk for blindness if untreated

  • Carotid or Vertebral DissectionCharacterized byHeadacheVertigoUnilateral Horner SyndromeSuspect if sudden neck rotation or extension urgent imaging and neurosurgery

  • CNS InfectionProtect yourself firstFever + headache=maskMeningitis: inflammation of arachnoid and pia mater caused by bacteria, virus or fungiHeadache, stiff neck, fever, chills, photophobia, confusion, phonophobia, nausea, vomiting, seizures (more common in children), rash, petechiae, Brudzinski or Kernig signsBacterial in 400 per 100,000 children, 1-2 per 100,000 adultsLong term complications of cognitive defects, epilepsy, hydrocephalus, hearing loss

  • CNS Infection (cont)Infection via subarachnoid space (encapsulated organisms), also at risk if head trauma, neurosurgery, immune suppressionViral meningitis-- typically less severe illness: enterovirus, mumps, CMV, HSV, adenovirus, HIVFungal may be severe, consider if immunosupressedTreatment: Support ABCs, treat for shock/sepsisdefinitive therapy is abx

  • CNS Infections continuedViral Encephalitis: infection of brain parenchyma (arbovirus, HSV, HVZ, EBV, CMV, Rabies, equine encephalitis, West Nile)New psychiatric sx, cognitive defect, seizures, movement disordersTreatment with antivirals

  • CNS Infections (cont)Brain Abscess: uncommon infection extending from otitis, hemotogenous or instrumentationClassic fever, headache, focal neuro deficit in less than one thirdSymptoms from focal and mass effect cause delayed diagnosisDiagnosis with imaging, LP, +/- biopsyTreatment: support ABCs, antibiotics

  • Tumor: 70% with headache, classically worse in the morning, positional, nausea and vomitingPseudotumor cerebri: headache worse with awakening, valsalva, cough, bendingSigns of increased ICP: papilledema, CN VI palsy, diploia, visual deficits, tinnitusLinked with OCP use, vit A, tetracycline use, thyroid disordersDiagnosed with CT for hydrocephalus, LP for high opening pressureTreatment diuretics, repeat LP, CSF shunt or optic nerve sheath fenestration

  • OpthalmicGlaucomaAcute angle closure: obstruction of aqueous humor outflow leading to increased intraocular pressure and possible blindnessSudden onset painful vision loss associated with headache, nausea, vomiting, somnolenceExam with decreased vision, conjunctival injection, hazy cornea, fixed/mid-position or dilated unreactive pupilNeeds emergent opthomology referral, eye gtts

  • OpthalmicIritis: inflamation of the IrisRisk if sarcoid, STDs, collagen vascular dzBlurred vision, deep eye pain, photophobia, red eyeExam with conjunctival injection, cell and flareOptho referral, topical steroids, cycloplegic dropsOptic Neuritis: painful vision loss due to inflammation of optic nerv