1. The Acute Headache Devorah Nazarian, M.D. Mount Sinai School of Medicine April 12, 2002

2. Patient Presentation HPI-35 y.o. female presents to the E.D. complaining of a severe headache. The patient states that she was on the subway going to work, a few hours ago, when she suddenly felt a severe sharp pain in her head. Associated symptoms include nausea, neck pain. Patient took Ibuprofen prior to arrival with no relief. PMH- Prior history of headaches which resolve with ibuprofen. Social-Denies alcohol or cocaine. Smokes “few” cigarettes on weekends Meds- OCP

3. Patient Presentation continued P.E.-Vitals Temp 97.4 BP 122/74 HR 90 RR 16 General: appears in discomfort with eyes shut Neuro: A&Ox3, CN II-XII intact, Motor 5/5 throughout, nl gait, sensory grossly intact, reflexes equal throughout HEENT: PERRL, EOMI, NCAT Neck: supple, -nuchal rigidity Chest: CTA-B Heart: RRR -M Abdomen: +bs, soft,ND, NT Extremities: FROM, -C/C/E Skin: no rashes, no signs of trauma

4. Introduction 1-3% of E.D. visits are for headache. Only 1-5% of those patients have a serious underlying problem.

5. Question # 1 Does a Response To Therapy Predict The Etiology of an Headache?

6. Causes of a Headache distention, traction, or dilation of intracranial or extracranial arteries traction or displacement of large intracranial veins or dural envelope compression, spasm, inflammation, and trauma to cranial & spinal nerves spasm, inflammation, and trauma to cranial & cervical muscles meningeal irritation & raised intracranial pressure disturbance of intracerebral serotonergic projections

7. Common Pathway for Pain Regardless of Underlying Etiology of the Headache HA pain of the scalp and face is transmitted via trigeminal nerve Regardless of the etiology once the trigeminovascular axons are stimulated a pathway starts resulting in the onset of pain Serotonin receptors are the main focus of pain management. The 5-HT1 receptor is thought to be the most important subtype in the common pathway of headache

8. So What Does the Evidence Show?

9. Response of Headaches in Nonnarcotic Analgesics Resulting in Missed Intracranial Hemorrhage Case series Presented 3 patients with headaches whose symptoms resolved with a variety of medications but returned with hemorrhage. Concluded that patients can have significant pathologic hemorrhage after successful treatment with nonnarcotic analgesics and release from the ED Seymour JJ, Moscati RM, Jehle DV,. Response of Headaches to Nonnarcotic Analgesics Resulting in Missed Intracranial Hemorrhage. AM J Emerg Med. 1995;13:43-45

10. Dihydroergotamine and Metoclopramide in the Treatment of Organic Headache Case series Patients were given nonnarcotic agents with complete pain relief and found to have inflammatory intracranial processes. Using response to pain can as indicator of etiology may miss potential problematic headache Gross DW, Donat JR, Boyle CA, Dihhydroergotamine and metocloperamide in the treatment of organic headache. Headache. 1995;35:637-638

11. Sumatriptan Relieves Migraine-like Headaches Associated with CO Exposure Case report One patient with a headache from CO poisoning who responded to sumatriptan Lipton RB, Mazer C, Newman LC, et al. Sumatriptan relieves migraine- like headaches associated with carbon monoxide exposure. Headache. 1997;37:392-395.

12. Patient Management Recommendation Level C Recommendation. Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.

13. Question # 2 Which Patients With Headache Require Neuroimaging in the ED?

14. What Is the Goal of Neuroimaging in the ED? To identify a treatable lesion. ACEP has categorized neuroimaging Emergent- essential for a timely decision regarding potentially life-threatening or severely disabling entities Urgent- arranged prior to discharge from the ED or, performed prior to disposition when follow-up cannot be assured Routine- indicated when the studies results are not considered to make a change in the patients disposition from the ED

15. So What Does the Evidence Show?

16. Patients With Headache and Abnormal Neurologic Exam Require Neuroimaging US Headache Consortium, reviewed articles dealing with chronic headache abnormality on neurologic exam increased the likelihood of positive results in a neuroimaging by 3 fold normal findings in a neurologic exam reduced the odds of positive findings in a neuroimaging study by 30% US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000

17. Predictors of Intracranial Pathologic Findings in Patients Who Seek Emergency Care Because of Headache retrospective random chart review 468 patients who presented to the ED with chief complaint of headache abnormal findings in neurologic exam had a PPV for intracranial pathology of 39% age greater than 55 was identified as clinical parameters associated with intracranial process no association found between type of HA and the final diagnosis Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of Headache. Arch Neurol. 1997;54:1506-1509

18. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache retrospective review ED patients complaining of acute HA or acutely worsening HA 333 patients evaluated 17 patients had “worst headache of life”; only one had positive CT results Does not support work-up for patients with worst headache Flawed Study Reinus WR, Wippold FJ, Erickson KK. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache. Emerg Radiol. 1994;94:67-70

19. Acute Headache of Recent Onset and Subarachnoid Hemmorrhage 1 year prospective study acute sudden-onset HA with normal neurologic findings all patients had CT, if CT was negative LP done patients were followed for 3 months 27 patients enrolled, 9 had SAH, 1 intraventricular hemorrhage, 1 bacterial meningitis, 1 with viral meningitis supports neuroimaging for patients with sudden acute onset headache Lledo A, calandre L, Marinez-Menendez B, et al. Acute Headache of Recent Onset and Subarachnoid Hemmorrhage : a Prospective Study. Headache. 1994;34:172-174

20. Further Support for Neuroimaging with Severe Headache Harling in a prospective study of patients presenting with thunderclap headache found 35/49 to have SAH on CT or LP. Mills in a prospective study found that 29% of patients receiving head CT for “worst headache of life” had positive CT findings. Both studies support imaging for acute sudden-onset headache Harling DW, Peatfield RC, Van Hille PT, et al Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90 MillsML, Russo Ls, Vines FS, Et al. High yield criteria for urgent cranial CT scans. Ann Emerg Med. 1986;15:1167-1172

21. Headache in HIV Related Disorders Prospective study 49 consecutive HIV patients with headache 82% had a serious identifiable cause. HIV positive patients with headache should be considered for CT and LP Lipton RB, Feraru ER, Weiss G, et al. Headache in HIV Related Disorders. Headache. 1991;31:518-522

22. A Decision Guideline For ED Utilization of Noncontrast Head CT in HIV Infected Patients prospective convenience sample 110 patients with neurologic complaints new seizure, depressed or altered mental status, and headache that was different in character or lasted longer than 3 days, identified all the cases of focal lesions in patients new or different HA was reported in 25% of the cases Rothman RE, Keyl PM, McArthur JC, et al. A decision guideline for the utilization of noncontrast head CT in HIV infected patients. Acad Emerg Med. 1999;6:1010- 1019

23. Patient Management Recommendations Level B Recommendations. Patients presenting to the ED with headache and abnormal findings on neurologic examination should undergo emergent noncontrast head CT. Patients presenting with acute sudden-onset headache should be considered for emergent head CT scan. HIV positive patients with a new type of headache should be considered for urgent neuroimaging study. Level C Recommendations. Patients who are older than 50 years old with a new type of headache without abnormal finding on neurologic exam should be considered for urgent neuroimaging.

24. Question # 3 Is There a Need for Emergent Angiograghy in the Patient with a “Thunderclap Headache” Who Has Negative Findings In Both CT and LP?

25. Thunderclap Headaches sudden-onset headache of excruciating pain reaching its maximal intensity within a few seconds suggest presence of subarachnoid hemorrhage (SAH) work-up: noncontrast CT and LP Day and Raskin presented a patient with 3 thunderclap headaches (TCHA) in 1 week and a negative work-up. An angiogram showed diffuse vasospasm and an unruptured aneurysm. Could a TCHA be a sign of hemorrhage into the wall or rapid expansion of aneurysm. Day JW, Raskin NH, Thunderclap Headache: symptom of unruptured aneurysm. Lancet 1986;2:68-70

26. So What Does the Evidence Show?

27. Long-Term Follow-up of 71 Patients With TCHA Mimicking SAH prospective follow-up study 71 patients who presented with TCHA with negative CT and LP followed for 3.3 years none developed SAH in follow-up period angiography is not needed in the work-up of patients with TCHA Wijdicks EF, Kerkhoff H, van Gijn J, Long-term follow-up of 71 patients with TCHA mimicking SAH. Lancet.1988,2:68-70

28. Vasospasm as a cause of TCHA Case reports total of 6 patients angiography on all patients revealed multifocal segmental vasospasm without aneurysm vasospasm is certainly one of the causes of TCHA Slivka A, Philbrook B, Clinical and angiographic features of thunderclap headache. Headache.1995;35,:1-6 Dodick DW, Brown RD, Britton JW, et al. Nonaneurysmal thunderclap headache with diffuse, multifocal, segmental, and reversible vasospasm. Cephalagia. 1999; 19:118-123

29. TCHA Is It a Migraine? prospective study 49 patients with TCHA, 14 patients had negative results patients followed for a minimum 18 months without adverse outcomes refutes the need for angiography in initial work-up of TCHA Harling DW, Peatfield RC, Van Hille PT, et al. Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90

30. The Clinical Spectrum of Unruptured Intracranial Aneurysms 111 patients with unruptured aneurysms 54 had symptomatic aneurysms 8 clinical syndromes of symptomatic unruptured aneurysms documented 7 patients with TCHA aneurysmal mechanism of TCHA included aneurysmal expansion, thrombosis, and intramural hemorrhage Raps EC, Rogers JD, GalettaSL, et al. The clinical spectrum of unruptured intracranial aneurysm. Arch Neurology. 1993;50:265-268

31. Identification and Treatment of Cerebral Aneurysms after Sentinel Headache case reports 2 patients with prolonged TCHA negative CT and LP angiograms showed aneurysms concluded that angiography needs to remain part of the work-up for TCHA Hughes RL. Identification and Treatment of Cerebral Aneurysms after Headache. Neurology. 1992;42:1118-1119

32. Other Entities Which Can Cause a TCHA cerebral venous thrombosis can present TCHA without neurologic findings vertebral artery dissection and internal carotid artery dissection often are associated a sudden severe headache

33. Patient Management Recommendations Level C Recommendations. Patients with a thunderclap headache who have negative findings on noncontrast head CT, normal opening pressure and negative findings on CSF analysis do not need emergent angiography. These patients can be discharged from ED with follow-up arranged with their primary care provider or neurologist.