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Basics ⬇

[Section Outline]

Author:

Joshua W.Joseph

Description!!navigator!!

Etiology!!navigator!!

Pediatric Considerations
Serious causes of headache in children are rare but those who come to the ED for this complaint should all have follow-up with a pediatrician

Geriatric Considerations
Older patients with new headache have a higher likelihood of a serious etiology and should have more thorough evaluation with a low threshold for imaging

Pregnancy Prophylaxis
In addition to all other causes of headache, pregnant women (and recently postpartum women) are at increased risk for CVST, eclampsia, PRES, and RCVS

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms!!navigator!!

History

  • Attributes of the pain - PQRST:
    • Provocative and palliative features:
      • Position of the head, coughing or straining (increase suggests elevated ICP), and movement
    • Quality:
      • Throbbing or continuous
      • Deep or superficial
      • Change compared to prior headaches
    • Region
    • Severity
    • Worst headache of life?
    • Timing
    • Sudden or gradual?
  • Associated findings:
    • Visual symptoms, dizziness, nausea, vomiting, witnessed loss of consciousness
  • Historical factors indicating additional testing:
    • New onset:
      • Age >50
      • HIV, transplant, or cancer patient?
    • Trauma or falls (even without headstrike)
    • Persistent vomiting
    • Any new focal neurologic or visual symptoms
  • Risk factors for cerebral sinus thrombosis:
    • Malignancy
    • Pregnancy (or postpartum)
    • Protein-S or protein-C deficiency
    • Oral contraceptive
    • Ulcerative colitis
    • Behçet syndrome

Physical Exam

  • Temperature and blood pressure
  • Complete neuro exam
  • Fundoscopy: Papilledema
  • Evaluate skin for rashes:
    • Zoster
    • Purpura
  • Palpate temporal arteries
  • Examine for meningismus
    • Nuchal rigidity
    • Kernig sign:
      • Thigh is flexed at the hip and knee at 90° and subsequent extension in the knee is painful
    • Brudzinski signs
      • Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
    • Symphyseal sign: Pressure on the symphysis pubis leads to abduction of the leg and reflexive hip and knee flexion
    • The cheek sign: Pressure on the cheek below the zygoma leads to rising and flexion in the forearm

Essential Workup!!navigator!!

Diagnostic Tests & Interpretation!!navigator!!

Lab

  • CSF:
    • Essential in suspected meningitis, subarachnoid hemorrhage (SAH)
  • ESR:

Imaging

  • Head CT scan:
    • Indications:
      • Uncertain diagnosis based on history and physical exam (leaving open the possibility of serious causes)
      • Signs of increased ICP
      • “First or worst” headache
      • Abrupt onset (thunderclap, immediate peak pain)
      • New focal neurologic abnormalities
      • Papilledema
      • Recurrent morning headache
      • Persistent vomiting
      • Associated with fever, rash, and nausea
      • Trauma with loss of consciousness, focal deficits, or lethargy
      • Onset during exertion
      • Altered mental status, meningismus
    • Definitive test for SAH if performed within 6 hr of onset and read by an attending radiologist
    • Within 24 hr, >95% sensitive (sensitivity falls rapidly with time and is 50% at 7 d out)
  • Sinus imaging may show acute sinusitis; chronic sinusitis rarely causes acute headache
  • MRI:
    • Indicated to assess for etiologies that are missed by CT scan and LP:
      • Posterior fossa lesion
      • Pituitary apoplexy
      • CVST
  • MRA:
    • Indicated if SAH suspected, CT is negative, and unable to perform lumbar puncture
    • Suspicion of carotid or vertebral dissection (e.g., recent neck manipulation or trauma)
    • Nonmigrainous vascular cause suspected (e.g., RCVS)

Diagnostic Procedures/Surgery

  • Lumbar puncture:
  • Perform CT first if:
    • New focal neurologic finding
    • Papilledema
    • Abnormal mental status
    • HIV positive or immunosuppressed
  • Detect intracranial and meningeal infections
  • Detect blood not evident on CT scan:
    • There is no specific threshold number of red cells below which SAH is excluded - the RBC count is a function of time from onset
  • Opening pressure:
    • Essential to diagnose pseudotumor cerebri and CVST
    • Can distinguish traumatic tap vs. true hemorrhage
  • Xanthochromia:
    • Should be visible by 12 hr after onset of a SAH
    • Visual inspection is the most commonly used method - spectrometry (is more sensitive but has a high false-positive rate)

Differential Diagnosis!!navigator!!

Treatment ⬆ ⬇

[Section Outline]

Initial Stabilization/Therapy!!navigator!!

ED Treatment/Procedures!!navigator!!

Medication!!navigator!!

ALERT
DO NOT use the response to any medication to indicate a benign cause of a headache

Follow-Up ⬆ ⬇

Disposition

Admission Criteria

  • Headache secondary to suspected organic disease
  • Intractable vomiting and dehydration
  • Pain refractory to outpatient management
  • Consider ICU admission:
    • Suspected symptomatic aneurysm
    • Acute subdural hematoma
    • SAH
    • Stroke
    • Increased ICP
    • Intracranial infection

Discharge Criteria

  • Most migraine, cluster, and tension headaches after pain relief
  • Local or minor systemic infections (e.g., URI)

Issues for Referral

Patients with recurrent headaches should have follow-up with a neurologist or PCP

Pearls and Pitfalls ⬆ ⬇

  • The sensitivity for detecting SAH on CT scan falls rapidly after 24 hr. LP remains essential for all patients with suspected SAH presenting after 6 hr of symptom onset
  • Neurology consultation should not delay urgent imaging in patients with high-risk features
  • Use dopamine antagonists with caution in patients with QT prolongation or electrolyte abnormalities. Use ergotamines and triptans carefully in patients with a documented history of CAD
  • Patients with chronic headaches and multiple visits benefit from consistent protocols for pain management; however, be alert to significant changes in their symptoms
  • Do not wait for LP results to empirically treat cases of suspected meningitis

Additional Reading ⬆ ⬇

Codes ⬆

ICD9

ICD10

SNOMED