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New Onset Headache: Diagnosis and Management Michelle Biros MS, MD Dept. Emergency Medicine Hennepin County Medical Center

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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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slide1

New Onset Headache:Diagnosis and Management

Michelle Biros MS, MD

Dept. Emergency Medicine

Hennepin County Medical Center

the case
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.

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
The Case (Continued)

Afebrile 114/68, HR 76, in NAD

General exam – normal

PERRLA, EOMI, Fundi-normal

Neck- supple

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

international headache society
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
headache
Headache
  • 1 of 10 top presenting complaints in the USA
  • 1 to 2% of visits to ED
  • 18 million outpatient visits
  • 78% of women and 64% of men had at least one headache in the last year
  • 36% of women and 19% men suffer from recurrent headaches
types of headaches in the ed
Types of Headaches in the ED

Final Diagnosis Percentage

  • Infection - not intracranial 39.3
  • Tension HA 19.3
  • Miscellaneous 14.9
  • Post-traumatic 9.3
  • Hypertension related 4.8
  • Vascular (Migraine) 4.5
  • No diagnosis 6.0
  • SAH 0.9
  • Meningitis 0.6
the case continued7
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 continued8
The Case ( continued)

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

sah most patients have
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
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
warning headaches
Warning Headaches
  • 20 - 50% have HA days or weeks before index episode- sentinel bleed
  • “Thunderclap” headache

Intense, acute, peak intensity at onset

Develop in secs: Maximal intensity in mins

Differential = SAH, Cerebral venous thrombosis, expansion of unruptured aneurysm, exertional HA

intracranial aneurysms
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
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%
physicians consistently misdiagnose sah
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
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
  • Sensitivity decreases over time from onset of symptoms
acute ha of recent onset leido a headache 1994
Acute HA of Recent OnsetLeido A. Headache 1994
  • 9 of 27 (33%) : SAH
    • 4 (+) CT
    • 5 normal CT, (+) LP
  • 2 of 19 LPs: meningitis
  • CT scanning and LP should be done with first severe acute headache
morgenstern et al ann emerg med 1998
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 sensitivity sames acad emerg med jan 1996
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
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 pupil

Schull 1999; Math modeling- LP first at 12 hrs increases LPs by 9/100; reduces CTs by 81. Can use in selected patients.

traumatic taps
Traumatic Taps
  • “Impression” or “3-tube” method not reliable to r/o trauma
  • Hgb  bili, oxyhgb xanthrochromia
  • Best predictor of SAH in face of bloody tap ; timing important
  • Repeat tap , repeat CT, angiogram
slide21
Case
  • Assumed to have drug OD
  • Intubated, lavaged
  • SAH diagnosis entertained, CT
  • CT  (+ ) blood everywhere
  • Angio OR
lessons learned
Lessons learned
  • First visit minimized
    • language barrier, mild sx, got better,

neck pain administered

  • Second visit confusing
  • Paramedic assumptions carried over
  • History was most important
ad