1. Emergency Medicine Clerkship Rotation
“My head hurts”
Aliza Moledina MS3
Emergency Medicine Clerkship Rotation
PAL Session April 29th, 2015

2. Case
Case: A 30 year old woman presents to the ED with a severe headache for the last 24 hours. Vitals: BP 140/90; P 85; RR 18.
The patient is holding her head and asks for the lights to be turned out. She then proceeds to vomit on you as you approach to examine her.
During your presentation please discuss the following:
What is the differential diagnosis of this patient?
What key features with the history and physical exam help diagnose this patient?(compare: migraine, tension headache, subarachnoid hemorrhage, meningitis)
When are head CT's and LP's required to diagnose the patient with a headache?
Discuss the ED treatment of migraine headaches.

3. Headache Classification Primary headache Secondary headache
benign, no organic cause
usually recurrent
Secondary headache
headache caused by underlying organic disease

4. Secondary Headaches 1) Vascular 2) Infection/Inflammatory 3) Traumatic
intracranial hemorrhage including SAH
SDH, EDH
Ischemic cerebrovascular disorder (ie stroke)
2) Infection/Inflammatory
meningitis, encephalitis
brain abscess
sinusitis
3) Traumatic
concussion, SDH, EDH

5. Secondary Headache 4) Autoimmune
vasculitis including temporal arteritis
5) Metabolic/Systemic
- hypoxia/hypercapnia, CO, hypoglycemia, preeclampsia
6) Iatrogenic
- medication induced - post LP
7) Neoplastic
- brain tumour, metastasis
8) Other
Acute angle closure glaucoma
post LP headache is caused by leakage of CSF from the dura and traction on pain sensitive structures

6. Primary headache
Tension
Cluster
Migraine

7. History History of Presenting Illness OPQRST
Onset - sudden vs gradual
Frequency, Duration, Progression
Alleviating/Precipitating Factors
Age at onset, pattern, trigger
Similar headaches in the past?
Prodrome/aura
Associated symptoms: neck stiffness, nausea and vomiting, photophobia/phonophobia, TMJ clicking, jaw claudication, neurological sx
Response to previous treatment
Relation to activity, food, alcohol
headache with exertion - rapid onset with exertion (sexual intercourse, exercise) esp with minor trauma raises possibility of carotid artery dissection or intracranial hemorrhage
headache that spreads into the lower neck (ie occipitonuchal headache) and between shoulders may indicate meningeal irritation due to either infection or subarachnoid blood - usually not blind
worse with bending/cough/valsalva  increased ICP
Classically the headache of raised ICP is worse in the morning. This has been attributed to a rise in ICP during the night as a consequence of recumbency, a rise in PCO2 during sleep caused by respiratory depression, and probably a decrease in CSF absorption - increase in CO2 -> brain venodilation -> cerebral congestion
- jaw claudication (pain comes on gradually when eating) - temporal arteritis
precipitating/alleviating factors (triggering factors, analgesics), medications (esp. nitrates,

8. History (continued) Review of Symptoms constitutional
neurological symptoms
visual changes
sinus symptoms - PODS
GI: nausea/vomiting
Pregnancy
Past Medical History:
immunosuppressed states, hx of malignancy, brain lesions/surgery, hx migraines
Medications/Allergies: including Acetaminophen, NSAID, triptan, opiods
anticoagulants, glucocorticoids
Family History SAH
Social History:
illicit drugs, toxic exposure (ie CO)

9. Red flags on history Headache of sudden rapid onset
History of altered mental status
Occipitonuchal radiation of headache
First severe headache after age 35
Prior or coexistent infectious disease
Onset during exertion
Immunosuppresion
Environmental exposure
possible indications for CT scan/further investigations

10. Physical Exam Vitals General: note traumatic findings
Full Neurologic exam - includes LOC, orientation, pupil symmetry, focal neurological deficits
HEENT- field of vision, fundoscopy (retinal hemorrhages, papilledema), red eye, temporal artery tenderness, sinus palpation, TMJ, otoscopy
Neck: meningismus
MSK - head and neck - muscles, tenderness
Kernigs/Brudzinski’s sign
ROS
vitals: temperature, blood pressure, pulse
neurologic exam: standing up from seated position, gait (tandem, Romberg), cranial nerve, motor, sensory, reflex, cerebellar coordination test
complete eye exam including field of vision and fundoscopy for papilledema
ENT: otoscopy
neck: examine for meningismus (resistance to passive neck flexion)
vascular exam: examine temporal and neck arteries; palpate and auscultate for bruit at neck, eye and head for arteriovenous malformation
MSK exam: examine spine and neck muscles; palpate head, neck and shoulder for tenderness,

11. Physical exam
Kernig

12. Brudzinski’s sign

13. Red flags on physical Papilledema Altered LOC
Fever or toxic appearance
Meningismus
Focal neurological deficits
Signs of head trauma

14. When to order head CT/LP?
CT head:
1 or more high risk features on history or physical (see red flag signs)
LP if SAH or infection are in the differential diagnosis
LP always performed in patients with suspected SAH in whom the CT scan is normal.

15. Meningitis inflammation of meninges Epidemiology:
cases in Canada per year
bimodal distribution: young children < 2 years and elderly >50
cases in Ottawa per year
with vaccination, meningitis in children is decreasing and tend to occur only in neonates

16. Meningitis Organisms: Streptococcus pneumoniae:
Neisseria meningitis (Meningococcus)
Hemophilus influenzae
Other organisms:
Children: GBS, E.coli
Elderly (>50) and comorbidities: Listeria monocytogens
1) streptococcus pneumoniae (Pneumococcus), a gram positive cocci
2) Neisseria meningitidis (Meningococcus), a gram negative cocci
3) Hemophilus influenzae, a gram negative bacilli

17. Meningitis Symptoms pro-drome of malaise or URTI
classic triad: fever, nuchal rigidity, change in mental status
headache
photophobia
confusion/lethargy or coma
seizure
petechial rash and palpable purpura
(meningococcal meningitis)
headache usually severe and generalized
older adults esp with underlying cond of DM or cardiopulmonary disease may present insidiously with lethargy or obtundaiton, no fever, and variable signs of meningeal inflammation

18. Meningitis Signs +/- cranial nerve abnormalities meningismus
Positive Kernig’s
thigh extended at 90 degrees and knee flexed at 90 degrees
pain and resistance when extending the flexed knee

19. Meningitis Positive Brudzinski’s sign patient lies supine on bed
passive flexion of neck elicits reflex flexion of hips

20. Investigation CBC, lytes, blood C+S
CSF: Lumbar puncture most important
opening pressure, cell count + differential, glucose, protein, Gram stain, bacterial C&S
AFB, fungal C&S, cryptococcal antigen in immunocompromised patients, subacute illness,
suggestive travel history or TB exposure
PCR for HSV, VZV, EBV, enteroviruses if viral cause suspected
Imaging: CT head/MRI
usually normal in meningitis
EEG if focal neuro signs present

21. CT head before LP: One or more of the following risk factors
immunocompromised state
Hx of CNS disease (mass lesion, stroke, focal infection)
New onset seizure (within one week of presentation)
Papilledema
Abnormal LOC
Focal neurological deficit

22. CSF Analysis
gram stain and culture help differential between bac and viral infection
normal CSF: <50 mg/dl of protein, CSF to serum glucose > 0.6, <5 WBC/microL, l
altered glucose transport through BBB

23. Management of Meningitis
ABCs to stabilize patient
Early empiric therapy: do not wait for investigations
Age 1 month - 50 years: IV (cefotaxime or ceftriaxone) + vancomycin
elderly >50 and immunocompromised: IV (cefotaxime or ceftriaxone), vancomycin and ampicillin (add coverage for Listeria and GNB):
adjunctive dexamethasone in adults
control ICP

24. Subarachnoid Hemorrhage
Definition: bleeding into subarachnoid space
Etiology
trauma (most common)
spontaneous
ruptured aneurysms (75-80%)
idiopathic (14-22%)
AVM (4-5%)
subarachnoid space - between arachnoid and pia

25. SAH Epidemiology: Clinical Features spontaneous SAH
10-28 / population/year
Peak age 55-60, 20% under age 45
Clinical Features spontaneous SAH
sudden onset severe “thunderclap headache” usually after exertion (“worst headache of my life”)
nausea/vomiting, photophobia
meningismus (irritation of meninges): positive Kernigs and Brudzinski’s
decreased LOC
focal deficits
ocular hemorrhage in 20-40%
reactive HTN

26. SAH Investigations non contract CT
LP - if CT negative but high suspicion.
elevated opening pressure (> 18 cm H2O)
bloody initially, xanthrochromic supernatant with centrifugation (“yellow”) by 12 h, lasts 2 weeks
CT or MR angiogram (aneurysm gold standard)

28. SAH Treatment
stabilize patient - monitor vitals, ECG for arrhythmias, analgesia
Stop source of bleeding
ruptured aneurysm: endovascular coiling or surgical clipping
Acute management
lower BP with IV labetalol
Short term management
hospitalize 1-2 weeks for monitor, use supportive care
if new neurological symptoms, transcranial doppler or cerebral angio to monitor for vasospasm

29. Primary Headaches 3 main: tension headache migraine headache
cluster headache (not discussed today)

30. Migraine
Onset can be associated with trigger such as food, stress, sleep disturbance, hormonal changes
4 stages: prodrome  aura  headache  post-drome
Aura: reversible cognitive dysfunction
gradual buildup over 5-20 minutes and lasts less than 60 minutes
visual, sensory and/or speech symptoms
flickering lights, spots or lines, loss of vision, scintillating scotoma
sensory: parasthesia and numbness
speech: dysphasic speech disturbances
scintillating scotoma (flashing jagged line of light spreading across visual field leaving blind spot) is a common presentation of aura

31. Migraine headache unilateral throbbing and pounding
usually localized to frontotemporal region, may radiate to neck
usually between 4 hours - 3 days
+/- nausea/vomiting, photophobia or phonophobia
Clinical diagnosis, diagnosis of exclusion

32. Migraines Treatment in Emergency department moderate-severe migraine
abortive therapy with Triptans (ex Sumatriptan 6 mg SC)
if N/V - then antiemetics/dopamine receptor antagonist (ex Metoclopramide 10 mg IV or prochlorperazine 10 mg IV)
diphenhydramine mg IV q1 hour up to 2 doses to presevent akathisia and dystonia from metoclopramide or prochlorperazine
Prevent early recurrence with steroid Dexamethasone mg IV or IM
IHS diagnostic criteria for migraine without aura
patient diagnosed with migraine without aura if he / she has all of the criteria below
A) >5 attacks fulfilling criteria B-D
B) headache lasting 4 to 72 hours that is untreated or unsuccessfully treated
C) headache with >2 of the following characteristics
unilateral location
pulsating quality
moderate to severe intensity that inhibits or prohibits daily activities
aggravation by walking stairs or similar routine physical activity
D) headache accompanied by >1 of the following:
nausea and / or vomiting
photophobia and phonophobia
E) headache not attributed to another disorder
2) IHS diagnostic criteria for migraine with aura
patient diagnosed with migraine with aura if he / she has all of the criteria below
A) >2 attacks fulfilling criteria B-D
B) aura with >1 of the following symptoms with no motor weakness
fully reversible visual symptoms
fully reversible sensory symptoms
fully reversible dysphasic speech disturbance
C) aura with >2 of the following characterics
homonymous visual symptoms (loss of vision or blurring of central vision) and / or unilateral sensory symptoms
>1 aura symptom develops gradually >5 minutes and / or different aura symptoms occur in succession over >5 minutes
each aura symptom last between 5 to 60 minutes
D) headache fulfilling migraine without aura

33. Tension Headache most common headache, lifetime prevalence 30-80%
episodic or chronic
band-like or vice like pressure, usually bilaterally
pain typically mild to moderate, not severe
not aggravated by routine physical activity
no nausea/vomiting/photophobia/phonophobia
Diagnosis of exclusion

34. Management of tension headache
Lifestyle modification
relieve stress
Analgesic if episodic
NSAID, acetaminophen
TCA (amitriptyline) - 1st line for chronic tension headache
NaSSA (mirtazapine) or SNRI (venlafaxine) is 2nd line

36. Questions?
Thank you 

37. References
Uptodate
Medscape
Lifeinthefastlane.com
Toronto Notes 2014