New Onset Headache: Diagnosis and Management Michelle Biros MS, MD Dept. Emergency Medicine Hennepin County Medical Center. The Case. Visit One- A 20 year old woman presents with a headache for three days. Emesis x1. No photophobia, fever, URI symptoms or visual changes.
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New Onset Headache:Diagnosis and Management
Michelle Biros MS, MD
Dept. Emergency Medicine
Hennepin County Medical Center
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.
Afebrile 114/68, HR 76, in NAD
General exam – normal
PERRLA, EOMI, Fundi-normal
Neurologic exam – normal
Relief 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
Final Diagnosis Percentage
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.
BP= 110/80: HR= 120: RR= 6: Afebrile
GCS= 3+2+3= 8
General exam- Atraumatic: not protecting her airway
Neuro- Pupils midposition, sluggish
Corneals intact; sustained clonus
Course: RSI, CT, OR
Intense, acute, peak intensity at onset
Develop in secs: Maximal intensity in mins
Differential = SAH, Cerebral venous thrombosis, expansion of unruptured aneurysm, exertional HA
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 pupil
Schull 1999; Math modeling- LP first at 12 hrs increases LPs by 9/100; reduces CTs by 81. Can use in selected patients.
neck pain administered