New Onset Headache: Diagnosis and Management Michelle Biros MS, MD Dept. Emergency Medicine Hennepin...
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Transcript of New Onset Headache: Diagnosis and Management Michelle Biros MS, MD Dept. Emergency Medicine Hennepin...
![Page 1: New Onset Headache: Diagnosis and Management Michelle Biros MS, MD Dept. Emergency Medicine Hennepin County Medical Center.](https://reader035.fdocuments.in/reader035/viewer/2022062421/56649c765503460f9492a32b/html5/thumbnails/1.jpg)
New Onset Headache:New Onset Headache:Diagnosis and ManagementDiagnosis and Management
Michelle Biros MS, MDMichelle Biros MS, MDDept. Emergency MedicineDept. Emergency Medicine
Hennepin County Medical CenterHennepin County Medical Center
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The CaseVisit One- A 20 year old woman presents with a headache for three
days. Emesis x1. No photophobia, fever, URI symptoms or visual changes.
Headache is severe, intermittent and throbbing, scalp / occiput, with radiation to the neck. No relief with OTC medications.
PMHx- unremarkable; no prior headaches.
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The Case (Continued)Afebrile 114/68, HR 76, in NADGeneral exam – normalPERRLA, EOMI, Fundi-normalNeck- suppleNeurologic exam – normalRelief with IM droperidol, 2.5 mg.Increased neck pain, thought to be a dystonic
rxn, resolved with benadryl. Dx: Tension HA vs Migraine vs Vascular
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International Headache Society
A first episode of severe headache cannot be classified as migraine
Nor as tension-type headache
First or worst headache requires evaluation
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1 of 10 top presenting complaints in the USA1 of 10 top presenting complaints in the USA
1 to 2% of visits to ED1 to 2% of visits to ED
18 million outpatient visits18 million outpatient visits
78% of women and 64% of men had at least 78% of women and 64% of men had at least one headache in the last yearone headache in the last year
36% of women and 19% men suffer from 36% of women and 19% men suffer from recurrent headachesrecurrent headaches
Headache
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Types of Headaches in the ED Final Diagnosis PercentageInfection - not intracranial 39.3Tension HA 19.3Miscellaneous 14.9Post-traumatic 9.3Hypertension related 4.8Vascular (Migraine) 4.5No diagnosis 6.0SAH 0.9Meningitis 0.6
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The Case ( continued)
One week later-
Found unresponsive with shallow respirations. No response to Narcan. Blood sugar = 115. Husband states has had no recent fever, trauma or drug use. States she has had headaches all week, worst today on waking. She also c/o neck pain. Became lethargic over a few hours.
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The Case ( continued)
BP= 110/80: HR= 120: RR= 6: AfebrileGCS= 3+2+3= 8General exam- Atraumatic: not
protecting her airwayNeuro- Pupils midposition, sluggishCorneals intact; sustained clonusCourse: RSI, CT, OR
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SAH: Most patients have...
Abrupt onset of severe, unique headache, or neck pain
Abnormal findings on neurologic examination
Subtle meningismus or ocular findings
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SAH…But not “Classic”
Roughly half have minor bleeding with atypical features
Nonstrenuous activities (34%)Sleep (12%)HA in any location (localized, generalized, mild)May be relieved by non-narcotic analgesicsDiagnosed as migraine, tension-type, sinusitis
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Warning Headaches20 - 50% have HA days or weeks before
index episode- sentinel bleed
“Thunderclap” headache Intense, acute, peak intensity at onsetDevelop in secs: Maximal intensity in mins
Differential = SAH, Cerebral venous thrombosis, expansion of unruptured aneurysm, exertional HA
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Intracranial Aneurysms
Women: men = 3 : 2 4 million Americans– 20% multiple aneurysms
Increase dx in mid-20s Peak incidence of 12% by age 60 Risk of spontaneous rupture 1 to 3%/yr– Peak 40 to 60 years
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Arteriovenous Malformations
10-15% of SAHSpontaneous hemorrhage– Any age but usually < 30
Incidence 3% per yearIncidence of major neurologic
deficit or mortality: 50%
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Physicians Consistently Misdiagnose SAH
• Failure to appreciate spectrum of clinical presentation
• Failure to understand limitations of CT
• Failure to perform and correctly interpret the results of LP
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Can a CT Scan Safely “Rule Out” SAH?
First diagnostic studyThin cuts ( 3 mm) through base of brainBlood on CT function of HgbSensitivity decreases over time from
onset of symptoms
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Acute HA of Recent OnsetLeido A. Headache 1994
9 of 27 (33%) : SAH– 4 (+) CT– 5 normal CT, (+) LP
2 of 19 LPs: meningitisCT scanning and LP should be
done with first severe acute headache
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Morgenstern, et al: Ann Emerg Med 1998
455 headaches & 107 “worst headache”
CT: 18 of 107 (17%): (+) SAH(-) CT/ (+) SAH by LP: Only 2 (2.5%)
Modern CT is sufficient to exclude 98% of SAH in patients
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SAH: CT SensitivitySames: Acad Emerg Med Jan 1996
181 adult patients with SAH– Sensitivity 91.2%• Pain < 24 hrs 93.1%• Pain > 24 hrs 83.8%
LP 100% sensitive if CT (-)“A normal NGCT does not reliably
exclude the need for LP”
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What about LP First?
Duffy et al; 1982: 55 patients with LP first - 7 immediately deteriorated
Hillman et al; 1986: 4 alert patients with SAH deteriorated after LP
Both :Clots on CT dilated pupilSchull 1999; Math modeling- LP first at 12
hrs increases LPs by 9/100; reduces CTs by 81. Can use in selected patients.
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Traumatic Taps
“Impression” or “3-tube” method not reliable to r/o trauma
Hgb bili, oxyhgb xanthrochromiaBest predictor of SAH in face of bloody
tap ; timing importantRepeat tap , repeat CT, angiogram
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Case
Assumed to have drug ODIntubated, lavagedSAH diagnosis entertained, CTCT (+ ) blood everywhereAngio OR
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Lessons learned
First visit minimized language barrier, mild sx, got better,
neck pain administered
Second visit confusingParamedic assumptions carried overHistory was most important