1. A Case of a Thunderclap Headache Andy Jagoda, MD, FACEP

2. Andy S. Jagoda, MD, FACEP Professor and Vice Chair Residency Program Director Department of Emergency Medicine Mount Sinai School of Medicine New York, NY

3. Andy Jagoda, MD, FACEP Objectives Review the focused neurologic exam in a patient with a sudden onset severe headache Review the differential diagnosis of sudden onset, severe headache Review the diagnostic approach to a patient with a sudden onset, severe headache

4. Andy Jagoda, MD, FACEP Case of Sudden Onset Severe Headache 32 year old female complained of a sudden, acute onset vertex headache radiating into her neck for 3 hours associated with nausea and lightheadedness. No PMH: No past history of headache Medications: None Family history: Not significant

5. Andy Jagoda, MD, FACEP Case Continued Appearance: 32 year old female, alert, cooperative but appeared uncomfortable, holding the top of her head VSS: 118/76, 72, 16, 98.6 Head: Atraumatic Neck: Nontender, supple Heart:Regular, no murmurs, no clicks Lungs:Clear Abd:Soft, nontender

6. Andy Jagoda, MD, FACEP Key Components of the Physical Exam Mental status Cranial nerve II –Fundoscopic exam looking for papilledema –Swinging flashlight test for afferent nerve defect Cranial nerve III –Pupil size looking for evidence of extrinsic compression of the parasympathetic fibers Cranial IV and VI –The two longest intracranial cranial nerves

7. Andy Jagoda, MD, FACEP Differential Diagnosis of Severe Sudden Onset Headache Subarachnoid hemorrhage Venous sinus thrombosis Idiopathic intracranial hypertension Carotid or vertebral artery dissection

8. Andy Jagoda, MD, FACEP Does response to therapy predict the etiology of an acute severe headache? All HA pain is mediated by serotonin receptors Case series / case reports (Class III evidence) –Seymour. Am J Emerg Med 1995. 3 patients treated with ketorolac or prochlorperazine with resolution of headache / Discharged / All with catastrophic outcomes –Gross. Headache 1995. 3 cases of meningitis with resolution of pain with DHE and metoclopramide Pain response can not be used as an indicator or the underlying etiology of an acute headache. ACEP Clin Pol. Ann Emerg Med 2002;108

9. Andy Jagoda, MD, FACEP Which patients with acute headache require neuroimaging in the ED? Neuroimaging is obtained to assess for treatable lesions: SAH, CVT, tumors, hydrocephalus –(Less tangible: Patient reassurance) Abnormal neuro exam increases the likelihood of a positive CT 3 times (95% CI 2.3-4) Normal neuro exam is not predictive Location, vomiting, headache waking patient up, worsening with valsalva are not predictive ACEP Clin Pol. Ann Emerg Med 2002;108

10. Andy Jagoda, MD, FACEP Which patients with acute headache require neuroimaging in the ED? Severe sudden onset headache: –Lledo Headache 1994, prospective study: 9 of 27 had SAH (only 4 had a positive CT) –Mills Ann Emerg Med 1986, prospective study 42 patients: 29% with worst headache had a positive CT Headache in the HIV patient: –Lipton Headache 1991, prospective 49 patients: 35% had mass lesion –Rothman Acad Emerg Med 1999, prospective 110 pts: 24% had a focal lesion

11. Andy Jagoda, MD, FACEP Which patients with acute headache require neuroimaging in the ED? Patients presenting with an acute HA and an abnormal neurologic exam should have an emergent head CT Patients presenting with a sudden severe HA should have an emergent head CT HIV patients with a new type of headache should have an urgent head CT Patients over the age of 50 with a new type of headache should have an urgent neuroimaging study

12. Andy Jagoda, MD, FACEP What are the indications for LP in acute HA? Suspected SAH in a patient with a normal head CT –CT is 90 – 98% sensitive for acute SAH –Sensitivity decreases over time Suspected meningitis –LP without CT in patients with normal neuro exam including normal mental status and normal fundoscopic exam Suspected idiopathic intracranial hypertension –Headache with papilledema –Normal CT

13. Andy Jagoda, MD, FACEP Is there a need for an emergent angiography in the patient with a sudden onset, severe headache who has a negative CT / LP? Level C recommendation: Patients with a sudden onset, severe HA who have negative findings in a head CT scan, normal opening pressure, and negative findings in CSF analysis do not need emergent angiography and can be discharged from the ED with follow-up arranged with their primary care provider or neurologist.

14. Andy Jagoda, MD, FACEP Conclusions HA evaluation requires a careful neurologic exam that focuses on the mental status, and CN II, III, IV, VI Tx response does not predict the underlying etiology Patients with sudden severe HA require a CT; if negative a LP –If the LP is negative, consider observing and repeating if the onset of headache was less than 12 hours from the test If CT and LP are negative, consider unruptured aneurysmal disease and discuss need for cerebral angiography / MRA –Test can be done as an outpatient

15. Andy Jagoda, MD, FACEP Questions?? www.ferne.org ferne@ferne.org Andy Jagoda, MD Questions?? www.ferne.org ferne@ferne.org Andy Jagoda, MD Andy.Jagoda@msnyuhealth.org www.ferne.org jagoda_ha_bic_symp_sea_0805.ppt 8/3/2005 5:02 PM Andy Jagoda, MD, FACEP