New Onset Headache:New Onset Headache:Diagnosis and ManagementDiagnosis and Management

Michelle Biros MS, MDMichelle Biros MS, MDDept. Emergency MedicineDept. Emergency Medicine

Hennepin County Medical CenterHennepin County Medical Center

The CaseVisit 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 NADGeneral exam – normalPERRLA, EOMI, Fundi-normalNeck- suppleNeurologic exam – normalRelief 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

1 of 10 top presenting complaints in the USA1 of 10 top presenting complaints in the USA

1 to 2% of visits to ED1 to 2% of visits to ED

18 million outpatient visits18 million outpatient visits

78% of women and 64% of men had at least 78% of women and 64% of men had at least one headache in the last yearone headache in the last year

36% of women and 19% men suffer from 36% of women and 19% men suffer from recurrent headachesrecurrent headaches

Headache

Types of Headaches in the ED Final Diagnosis PercentageInfection - not intracranial 39.3Tension HA 19.3Miscellaneous 14.9Post-traumatic 9.3Hypertension related 4.8Vascular (Migraine) 4.5No diagnosis 6.0SAH 0.9Meningitis 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: AfebrileGCS= 3+2+3= 8General exam- Atraumatic: not

protecting her airwayNeuro- Pupils midposition, sluggishCorneals intact; sustained clonusCourse: 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 analgesicsDiagnosed as migraine, tension-type, sinusitis

Warning Headaches20 - 50% have HA days or weeks before

index episode- sentinel bleed

“Thunderclap” headache Intense, acute, peak intensity at onsetDevelop 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 SAHSpontaneous hemorrhage– Any age but usually < 30

Incidence 3% per yearIncidence 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 studyThin cuts ( 3 mm) through base of brainBlood on CT function of HgbSensitivity decreases over time from

onset of symptoms

Acute HA of Recent OnsetLeido A. Headache 1994

9 of 27 (33%) : SAH– 4 (+) CT– 5 normal CT, (+) LP

2 of 19 LPs: meningitisCT 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 SensitivitySames: 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 pupilSchull 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 xanthrochromiaBest predictor of SAH in face of bloody

tap ; timing importantRepeat tap , repeat CT, angiogram

Case

Assumed to have drug ODIntubated, lavagedSAH diagnosis entertained, CTCT (+ ) blood everywhereAngio OR

Lessons learned

First visit minimized language barrier, mild sx, got better,

neck pain administered

Second visit confusingParamedic assumptions carried overHistory was most important