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

2. 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.

3. 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

4. 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

5. 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

6. Types of Headaches in the ED
Final Diagnosis Percentage
Infection - not intracranial
Tension HA
Miscellaneous
Post-traumatic
Hypertension related
Vascular (Migraine)
No diagnosis
SAH
Meningitis

7. 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.

8. 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

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

10. 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

11. Warning Headaches
% 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

12. 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

13. 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%

14. 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

15. 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

16. 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

17. 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

18. SAH: CT Sensitivity Sames: Acad Emerg Med Jan 1996
181 adult patients with SAH
Sensitivity %
Pain < 24 hrs %
Pain > 24 hrs %
LP 100% sensitive if CT (-)
“A normal NGCT does not reliably exclude the need for LP”

19. 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.

20. 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

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

22. 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