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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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New Onset Headache:Diagnosis and Management

Michelle Biros MS, MD

Dept. Emergency Medicine

Hennepin County Medical Center


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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.


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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


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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


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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


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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


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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.


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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


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SAH: Most patients have...

  • Abrupt onset of severe, unique headache, or neck pain

  • Abnormal findings on neurologic examination

  • Subtle meningismus or ocular findings


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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


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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


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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


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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%


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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


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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


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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


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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


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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”


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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.


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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


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Case

  • Assumed to have drug OD

  • Intubated, lavaged

  • SAH diagnosis entertained, CT

  • CT  (+ ) blood everywhere

  • Angio OR


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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


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