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Evaluation of the Sudden and Severe Headache: Diagnosis and Management Michael Gerardi, MD, FAAP, FACEP Vice-Chairman, Department of Emergency Medicine.

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Presentation on theme: "Evaluation of the Sudden and Severe Headache: Diagnosis and Management Michael Gerardi, MD, FAAP, FACEP Vice-Chairman, Department of Emergency Medicine."— Presentation transcript:

1 Evaluation of the Sudden and Severe Headache: Diagnosis and Management Michael Gerardi, MD, FAAP, FACEP Vice-Chairman, Department of Emergency Medicine Morristown Memorial Hospital Director, Pediatric Emergency Medicine Children’s Medical Center Morristown, New Jersey 1 1 1

2 The Case One hour prior to ED presentation, a 42 year old man was jogging and “hit” by the worst headache of his life. It was associated with some nausea and the feeling as if he was going to pass out. He rested for 30 minutes but the headache persisted as a diffuse, throbbing pain radiating to the base of his skull.

3 The Case (Continued) EMS was called. The patient felt as if he could not concentrate, there was no confusion, nor was there any other focal neurologic complaint. There was no past medical history, no medications, no family history, and no significant use of alcohol, tobacco or other drugs.

4 If a patient presented with the worst headache of his life, what is the work-up that should be initiated? a. Non-contrast CT b. LP after neg. CT c. LP without CT d. CT, LP, and angiography 6 5 6

5 Objectives What is the differential of a “thunderclap headache”?
What is the sensitivity of neuroimaging in subarachnoid hemorrhage (SAH)? What constitutes a “positive” lumbar puncture in SAH and when should it be performed? Do patients with suspected SAH who have a negative CT and lumbar puncture require additional imaging to “rule-out” expanded but unruptured aneurysm? 2 2 2

6 Headache 1 of 10 top presenting complaints 1 to 2% of visits to ED
18 million outpatient visits 638 million days of work lost per year 78% of women and 64% of men had experienced at least one in the prior year 36% of women and 19% men suffer from recurrent headaches

7 Headache Most have primary headache disorders migraine tension
Only a few have treatable secondary causes that threaten life, limb, brain such as subarachnoid hemorrhage 1 - 4 % of headache visits

8 “Worst” Headache Normal exam: 12- 33% SAH Abnormal exam: 25% SAH
Initial hemorrhage may be fatal Early definitive surgery improves outcomes Patients with greatest likelihood of benefiting from surgery are most likely to receive incorrect diagnosis

9 Physicians Consistently Misdiagnose SAH
1. Failure to appreciate spectrum of clinical presentation 2. Failure to understand limitations of CT 3. Failure to perform and correctly interpret the results of LP

10 ED Goals in Headache Patients
1. Differentiate life-threatening from benign 2. Initiate prompt treatment 3. Provide prompt pain relief 4. Prevent drug seeking and refer 5. Minimize resource utilization in ED 6. Optimize patient use of ED 7. Increase pre-ED treatment and reduce ED use

11 Differential Diagnosis of Headache
Onset Location Associated symptoms Pain characteristics Duration Prior history Diagnostic tests Physical exam

12 Medical Conditions That Present With Headache
Pheochromocytoma Hyperthyroidism SLE Giant Cell Arteritis Fibromyalgia

13 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

14 Ped HA Compared to Literature: Serious Conditions
Author # Age Tumor Bleed Meningitis Burton Fodden Leicht Dopeshi Dickman

15 Causes of Headache That Require Specific Therapy
Subarachnoid hemorrhage Meningitis Encephalitis Cervicocranial-artery dissection Temporal arteritis Acute angle-closure glaucoma Hypertensive emergency

16 Causes of Headache That Require Specific Therapy
Carbon Monoxide poisoning Pseudotumor cerebri Cerebral venous and dural sinus thrombosis Acute stroke (hemorrhagic or ischemic) Mass Lesion tumor abscess intracranial hematoma parameningeal infection

17 Headache Danger Signals
Onset after 40 years new or different headache subacute HA that worsens exertion, sex, coughing, straining Worst ever experienced

18 Headache Danger Signals: Associated With Neurologic Change
Memory impairment Ataxia Drowsiness Sensory loss Signs of meningeal irritation

19 Headache Danger Signals: Associated With Neurologic Change
Progressive visual or neurologic change Confusion Weakness Loss of coordination Asymmetry of pupils, DTRs

20 Headache Danger Signals: Abnormal Medical Evaluation
Fever Chronic malaise Arthralgia HTN Myalgia Wt loss Tender, poorly pulsatile temporal arteries

21 Subarachnoid Hemorrhage
10% of all acute CVAs 30,000 persons/year 10 -16/100,000 1% of all ED patients with acute cephalgia

22 Subarachnoid Hemorrhage
Incidence of 16 /100,000 about 33,600 cases per year 54% secondary to ruptured aneurysm Without treatment, 40% of aneurysm pts. have recurrent bleeding Aneurysm pt who survives initial rupture and is treated conservatively: 50% survival at one year

23 Subarachnoid Hemorrhage
Onset: Acute Location: Global Ass Sx: N,V, meningismus, focal Pain: Worst ever Duration: Brief Prior Hx: No Dx tests: CT 80-90% Phys ex: Focal signs, LOC, meningismus

24 Subarachnoid Hemorrhage
Warning leaks in 50% CT misses up to 10% small leaks Suspect if: > 35 years no previous HA no fading of HA came on with exertion altered LOC or neuro deficits stiff neck

25 Subarachnoid Hemorrhage: Neurologic Findings
Sudden HA without localizing findings Altered mentation Confusion, lethargy Bilateral extensor plantar reflex Unusual to find focal deficits

26 Causes of Non-Traumatic Subarachnoid Hemorrhage
“Berry” aneurysms AVM Cerebral angiomas Mycotic aneurysm Extension from parenchymatous hemorrhage Anticoagulation therapy

27 Causes of Non-Traumatic Subarachnoid Hemorrhage
Systemic bleeding diathesis Hemorrhagic encephalitis Hemorrhagic cerebral vasculitis Hemorrhage into CNS tumors or metastases Unknown

28 Intracranial Aneurysms
Women: men = 3 : 2 4 million Americans 20% multiple aneurysms Increase in mid-20s Peak incidence of 12% by age 60 Risk of spontaneous rupture 1 to 3%/yr Peak 40 to 60 years

29 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%

30 Conditions Associated with Cerebral Aneurysm Development
HTN Polycystic kidney disease Connective tissue disorders Coarctation of aorta Pregnancy induced HTN Family history of CVAs Bacterial endocarditis

31 Warning Headache % patients with SAH have HA days or weeks before index episode unusually severe distinct “Thunderclap” headache Day and Raskin 1996 intense, acute, peak intensity at onset develop in seconds maximal intensity in minutes lasts hours to days

32 “Thunderclap” Headache
25% associated with SAH “Warning” headache followed by SAH in 5% to 60% Expansion or dissection of unruptured aneurysm Cerebral venous thrombosis Exertional / coital headache

33 Subarachnoid Hemorrhage: Morbidity and Mortality
28,000 ruptured aneurysms 10, ,000 dead/disabled available for Rx 3, , , ,000 died rapidly misdiagnosed dead or functional no warning or missed disabled survivors

34 Misdiagnosis of Symptomatic Cerebral Aneurysm: Mayer 1996
217 patients with symptomatic SAH 54 / 217 misdiagnosed 46 / 217 minimal findings viral meningitis 15% migraine 13% uncertain etiology 13% Failure to consider SAH

35 Missed Cerebral Aneurysms Mayer 1996
9 / 43 (21%) CTs initially read as neg. 6 of these 9 : (+) SAH 48% re-bleed or deteriorated (vs. 2%) Good or excellent outcomes 91% initially correct 53% if misdiagnosed

36 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

37 SAH…But not “Classic” Prominent neck pain Cervical sprain, arthritis
Confusion, agitation, restless psychiatric diagnoses Syncope / trauma Traumatic SAH Syncope / abnormal ECG “MI and then trauma” 91% SAH have cardiac dysrhythmias and ECGs mimicking ischemia

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

39 International Headache Society
A first episode of severe headache cannot be classified as migraine: more than 4 episodes nor as tension-type headache: more than 9 episodes First or worst headache requires evaluation as do qualitatively different headaches

40 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 Hgb < 10: blood isodense Sensitivity decreases over time from onset of symptoms

41 Acute HA of Recent Onset Leido A. Headache 1994
27 patients; yo 1 hr to 13 days after HA onset no previous similar HA no focal neurologic signs all had CT; LP if CT neg

42 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 should be done with first severe acute headache

43 CT & Subarachnoid Hemorrhage: Sames et al: 1996
Sensitivity of NGCT: Group 1 (symptoms < 24 hrs) 93.1% Group 2 (symptoms > 24 hrs) 83.8% “A normal NGCT does not reliably exclude the need for LP”

44 SAH: CT Sensitivity Sames: Acad Emerg Med Jan 1996
181 patients; aged with SAH Sensitivity % pain < 24 hrs % pain > 24 hrs % LP 100% sensitive if neg CT “A normal NGCT does not reliably exclude the need for LP”

45 SAH Diagnosis: LP Needed Sidman: Acad Emerg Med Sep 1996
140 patients; aged 10-88 Sensitivity of CT < 12 hrs 80/ % > 12 hrs 49/ % Overall, 11/140 had (-) CT and (+) LP overall sensitivity %

46 Morgenstern LB, et al: Worst headache and SAH: Prospective, modern CT and spinal fluid analysis. Ann Emerg Med Sept 1998. 38,730 patients over 16 months, prospectively screened for “worst HA” Blinded neuroradiologists Neg CT LP cell count x 2 visual and spectrophotometric detection of xanthochromia CSF D-dimer assay

47 Morgenstern, et al: Ann Emerg Med 1998
455 headaches & 107 “worst headache” CT: 18 of 107 (17%): (+) SAH (-) CT/ (+) SAH: Only 2 (2.5%) (95% CI, 0.3%to 8.8%) Modern CT is sufficient to exclude 98% of SAH in patients

48 Morgenstern, et al: Ann Emerg Med 1998 (107 “Worst HA’s)
Variables CT-/LP CT+ CT-/LP+ Photophobia Stiff neck Nausea Lethargy Time < 24 h Migraine Headache

49 CT is Normal: Do LP? Yes!

50 What about LP First? Duffy et al; 1982: 55 patients who underwent LP as initial w/u Condition deteriorated immediately in 7 patients Hillman et al; 1986: 4 alert patients with SAH who deteriorated after lumbar puncture Both studies: clots on CT or a dilated pupil

51 LP First? Schull: Acad Emerg Med 1999
CT sensitivity: 86% LP after 12 hours: 100% Mathematical modeling for 100 patients 9 more LPs 81 fewer CT scans

52 Traumatic Taps 20% of LPs 0.5% and 6% has incidental intracranial aneurysm Impression or “3-tube” method not reliable in detecting traumatic tap Erythrocytes disseminate rapidly Released Hgb oxyhemoglobin xanthochromia bilirubin

53 Xanthochromia Bilirubin, enzyme-dependent process, is diagnostically more reliable but: takes up to 12 hours Timing is important CSF should be centrifuged and examined promptly so RBCs don’t undergo lysis in vitro, causing xanthochromia from oxyhemoglobin

54 Xanthochromia vs. Erythrocytes
primary criterion for SAH if neg CT advocates: spectrophotometry Erythrocytes considered more accurate by some used visual inspection which can miss discoloration in up to 50%

55 Timing the Tap With spectrophotometry, and waiting 12 hours after onset of headache: very accurate traumatic tap done earlier does not lead to xanthochromia and confusion Waiting: prolongation of ED stay risk “ultra-early” rebleeding

56 Normal CT & Persistently Bloody CSF ???
Not prudent to delay LP Without xanthochromia and clinical suspicion is high? Vascular imaging Xanthochromia present and clinical suspicion is high?

57 Thunderclap Headache: NL CT & NL LP - Vascular Imaging?
Unruptured cerebral aneurysm Day and Raskin: 1 patient - clipped Raps et al: 7 patients Witham: 1 patient - very thin aneurysm dome; clipped

58 Thunderclap Headache: NL CT & NL LP Vascular Imaging?
Wijdicks et al; Lancet, 1988 Retrospective evaluation 71 patients no SAH in 3.3 years f/u Half dx’d with migraine or tension HA Markus 1991; Linn 1994; Harling 1989 117 patients no SAH, no sudden deaths

59 SAH High Risk Factors Clinical History
Onset of HA: abrupt, maximal at onset, “thunderclap” headache Severity of headache: usually the “worst of life” or very severe Quality: First of this intensity; unique or different Associated signs / sx’s: LOC, diplopia, seizure, focal neurologic signs

60 SAH High Risk Factors: Epidemiologic
Cigarette smoking Hypertension Alcohol consumption (binge?) Personal or family history Polycystic kidney disease Heritable connective tissue diseases Sickle Cell Anemia Pregnancy and childbirth Valsalva maneuver Coitus Cocaine abuse Amphetamines

61 Predisposing Factors for Aneurysmal Rupture
Pregnancy and childbirth Poorly controlled HTN Valsalva maneuver Coitus Heavy ETOH consumption Cocaine abuse Amphetamines

62 HA: Cough, Exertional, & Sex Pascual: Neurology 1996
72 patients Intracranial lesions on neuroimaging cough-induced 17 / % exertional 12 / % sex / %

63 HA: Cough, Exertional, & Sex Pascual: Neurology 1996
Cough-induced: underlying lesion was always Chiari type I malformation Indomethacin- effective in benign but not with underlying lesions SAH 10 / 12 : exercise - induced 1/ 14 : sexual activity

64 HA: Cough, Exertional, & Sex Pascual: Neurology 1996
ALL patients with SAH: single HA prolonged severe generally accompanied by nausea vomiting photophobia

65 Subarachnoid Hemorrhage: Morbidity and Mortality
28,000 ruptured aneurysms 10, ,000 dead/disabled available for Rx 3, , , ,000 died rapidly misdiagnosed dead or functional no warning or missed disabled survivors

66 Acute Headache Questions ?

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