Presentation on theme: "New Onset Headache: Diagnosis and Management"— Presentation transcript:
1New Onset Headache: Diagnosis and Management Michelle Biros MS, MDDept. Emergency MedicineHennepin County Medical Center111
2The 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.
3The Case (Continued) Afebrile 114/68, HR 76, in NAD General 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
4International Headache Society A first episode of severe headache cannot be classified as migraineNor as tension-type headacheFirst or worst headache requires evaluation
5Headache 1 of 10 top presenting complaints in the USA 1 to 2% of visits to ED18 million outpatient visits78% of women and 64% of men had at least one headache in the last year36% of women and 19% men suffer from recurrent headaches
6Types of Headaches in the ED Final Diagnosis PercentageInfection - not intracranialTension HAMiscellaneousPost-traumaticHypertension relatedVascular (Migraine)No diagnosisSAHMeningitis
7The 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.
8The Case ( continued) BP= 110/80: HR= 120: RR= 6: Afebrile GCS= 3+2+3= 8General exam- Atraumatic: not protecting her airwayNeuro- Pupils midposition, sluggishCorneals intact; sustained clonusCourse: RSI, CT, OR
9SAH: Most patients have... Abrupt onset of severe, unique headache, or neck painAbnormal findings on neurologic examinationSubtle meningismus or ocular findings
10SAH…But not “Classic”Roughly half have minor bleeding with atypical featuresNonstrenuous activities (34%)Sleep (12%)HA in any location (localized, generalized, mild)May be relieved by non-narcotic analgesicsDiagnosed as migraine, tension-type, sinusitis
11Warning Headaches% have HA days or weeks before index episode- sentinel bleed“Thunderclap” headacheIntense, acute, peak intensity at onsetDevelop in secs: Maximal intensity in minsDifferential = SAH, Cerebral venous thrombosis, expansion of unruptured aneurysm, exertional HA
12Intracranial Aneurysms Women: men = 3 : 24 million Americans20% multiple aneurysmsIncrease dx in mid-20sPeak incidence of 12% by age 60Risk of spontaneous rupture 1 to 3%/yrPeak 40 to 60 years
13Arteriovenous Malformations 10-15% of SAHSpontaneous hemorrhageAny age but usually < 30Incidence 3% per yearIncidence of major neurologic deficit or mortality: 50%
14Physicians Consistently Misdiagnose SAH Failure to appreciate spectrum of clinical presentationFailure to understand limitations of CTFailure to perform and correctly interpret the results of LP
15Can 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
16Acute HA of Recent Onset Leido A. Headache 1994 9 of 27 (33%) : SAH4 (+) CT5 normal CT, (+) LP2 of 19 LPs: meningitisCT scanning and LP should be done with first severe acute headache
17Morgenstern, 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
18SAH: CT Sensitivity Sames: Acad Emerg Med Jan 1996 181 adult patients with SAHSensitivity %Pain < 24 hrs %Pain > 24 hrs %LP 100% sensitive if CT (-)“A normal NGCT does not reliably exclude the need for LP”
19What about LP First?Duffy et al; 1982: 55 patients with LP first - 7 immediately deterioratedHillman et al; 1986: 4 alert patients with SAH deteriorated after LPBoth :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.
20Traumatic Taps“Impression” or “3-tube” method not reliable to r/o traumaHgb bili, oxyhgb xanthrochromiaBest predictor of SAH in face of bloody tap ; timing importantRepeat tap , repeat CT, angiogram
21Case Assumed to have drug OD Intubated, lavaged SAH diagnosis entertained, CTCT (+ ) blood everywhereAngio OR
22Lessons learned First visit minimized Second visit confusing language barrier, mild sx, got better,neck pain administeredSecond visit confusingParamedic assumptions carried overHistory was most important