New Onset Headache: Diagnosis and Management Michelle Biros MS, MD Dept. Emergency Medicine Hennepin County Medical Center 1 1 1

The Case Visit 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.

The Case (Continued) Afebrile 114/68, HR 76, in NAD General exam – normal PERRLA, EOMI, Fundi-normal Neck- supple Neurologic exam – normal Relief 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

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

Headache 1 of 10 top presenting complaints in the USA 1 to 2% of visits to ED 18 million outpatient visits 78% of women and 64% of men had at least one headache in the last year 36% of women and 19% men suffer from recurrent headaches

Types of Headaches in the ED Final Diagnosis Percentage Infection - not intracranial 39.3 Tension HA 19.3 Miscellaneous 14.9 Post-traumatic 9.3 Hypertension related 4.8 Vascular (Migraine) 4.5 No diagnosis 6.0 SAH 0.9 Meningitis 0.6

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.

The Case ( continued) BP= 110/80: HR= 120: RR= 6: Afebrile GCS= 3+2+3= 8 General exam- Atraumatic: not protecting her airway Neuro- Pupils midposition, sluggish Corneals intact; sustained clonus Course: RSI, CT, OR

SAH: Most patients have... Abrupt onset of severe, unique headache, or neck pain Abnormal findings on neurologic examination Subtle meningismus or ocular findings

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 analgesics Diagnosed as migraine, tension-type, sinusitis

Warning Headaches 20 - 50% have HA days or weeks before index episode- sentinel bleed “Thunderclap” headache Intense, acute, peak intensity at onset Develop in secs: Maximal intensity in mins Differential = SAH, Cerebral venous thrombosis, expansion of unruptured aneurysm, exertional HA

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

Arteriovenous Malformations 10-15% of SAH Spontaneous hemorrhage Any age but usually < 30 Incidence 3% per year Incidence of major neurologic deficit or mortality: 50%

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

Can a CT Scan Safely “Rule Out” SAH? First diagnostic study Thin cuts ( 3 mm) through base of brain Blood on CT function of Hgb Sensitivity decreases over time from onset of symptoms

Acute HA of Recent Onset Leido A. Headache 1994 9 of 27 (33%) : SAH 4 (+) CT 5 normal CT, (+) LP 2 of 19 LPs: meningitis CT scanning and LP should be done with first severe acute headache

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

SAH: CT Sensitivity Sames: 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”

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 pupil Schull 1999; Math modeling- LP first at 12 hrs increases LPs by 9/100; reduces CTs by 81. Can use in selected patients.

Traumatic Taps “Impression” or “3-tube” method not reliable to r/o trauma Hgb  bili, oxyhgb xanthrochromia Best predictor of SAH in face of bloody tap ; timing important Repeat tap , repeat CT, angiogram

Case Assumed to have drug OD Intubated, lavaged SAH diagnosis entertained, CT CT  (+ ) blood everywhere Angio OR

Lessons learned First visit minimized Second visit confusing language barrier, mild sx, got better, neck pain administered Second visit confusing Paramedic assumptions carried over History was most important