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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