Headache and Subarachnoid Hemorrhage

1. Headache and Subarachnoid Hemorrhage Carly Thompson February 19, 2009 See Rob Halls’ presentation at the end of Carly’s

2. Objectives • Approach to headache in the ED • Migraine • Focus on dx, tx • Subarachnoid Hemorrhage • Other causes of serious headache

3. Headache Epidemiology • 4% of ED visits • Primary Headaches • Migraine • Tension-Type • Cluster • Secondary • All others! • 1% of headaches are SAH!

4. Headache: Historical Features

5. Question: • Name 5 high risk historical features for Subarachnoid Hemorrhage.

6. High Risk Features for SAH • Thunderclap • First or worst headache of my life • Altered mental status / Seizure • Headache with exertion / intercourse • History of exercise • Location of pain: occipitonuchal • PPV occipitonuchal headache for intracranial pathology is 16% • Family history of SAH • Up to 4x increased risk in 1st and 2nd degree relatives!

7. Question • What is your differential for thunderclap headache? Name 3 (other than SAH). Thunderclap = sudden-onset, severe headache

8. Thunderclap Headache: Differential Diagnosis • SAH • Carotid or vertebral artery dissections • Venous sinus thrombosis • Pituitary apoplexy • Hypertensive emergencies • Cluster headache • Cerebellar CVA

9. High Risk Examination Findings • Vital signs: htn, fever • Decreased, altered, fluctuating LOC • Focal neurologic sign • Meningismus • Toxic appearance • Opthamalogic findings: papilledema, subhyaloid hemorrhage, retinal hemorrhages, decreased vision, ciliary flush, sluggish pupillary light response • Trauma • Temporal artery findings • Carotid bruit • Nausea and vomiting: Increased ICP, hemorrhage, ANAG • Nasal discharge with sinus tenderness: sinusitis

10. Question • What is a subhyaloid hemorrhage and when do you see it?

11. Subhyaloid Hemorrhage • Gravity-dependent venous hemorrhage between retina and vitreous membrane, convex at bottom, and flat at top when sitting • Highly suggestive of SAH: 11-33% of SAH cases • Terson’s syndrome – rapid increase in ICP assoc. with hemorrhage – worse outcome

12. Low Risk Patient • No change in headache pattern • No new concerning historical features • No focal neurologic symptoms or findings No imaging indicated! • Meta-analysis: • 2.4% of those with normal neuro exam have neurologic abnormalities on CT • 0.4% of those with typical migraine symptoms

13. Question • Which subsets of patients with headache require neuroimaging in the ED? • Name 3 groups.

14. Neuroimaging Indications ACEP Clinical Policy (Ann Emerg Med 2008) • Level B (1) Headache and new abnormal neuro findings • PPV 39% for intracranial pathology • LR 3.0 (2) Sudden-onset severe headache • 10-15% have serious pathology, often SAH (3) HIV patients with new headache • Headache – 35% had mass lesion • Neurologic complaint – 24% focal lesion • 1 or more of predicted all focal lesions in a series of patients: • New seizure • Depressed / altered LOC • Headache different or > 3 days

15. Neuroimaging Level C Evidence • Age >50 with new headache but normal exam, should be considered for urgent neuroimaging • OR 3.3 of pathologic diagnosis

16. Neuroimaging • Other worrisome features that increase probability of positive findings, but no clear recommendations: • Occipital location • Worsening with Valsalva • Headache waking from sleep • Associated syncope • Nausea or sensory distortion

17. Neuroimaging Headache in Pregnancy • Most headaches are benign • CVA – risk increases 3-13x • SAH – 20/100,000 deliveries • Migraines: less common • 60-70%have improvement in migraines during pregnancy Conclusion: Insufficient data to drive recommendations for imaging.

18. Question • Can response to therapy be used as a diagnostic tool?

19. Response to Therapy Level C • No!!! Pain response should not be used. • ? Common pathway for pain regardless of etiology • No RCT to support or refute this. • Class III Evidence: Case reports, case series, showing resolution or improvement in pain with analgesics in SAH, meningitis, CO-induced headache, cerebral venous sinus thrombosis, dissection, etc.

20. Migraine • What are the diagnostic criteria for migraine?

21. Migraine: Diagnosis • Recurrent headache disorder – IHS Criteria • Headache lasts 2-72 hours • At least 2 of: • Unilateral • Pulsating • Moderate to Severe • Aggravation by routine activity • At least 1 of: • Photophobia or Phonophobia • Nausea and/or vomiting • At least 5 attacks • Hx, physical and neurologic exam do not suggest other organic disease

22. Migraine: Diagnosis • Migraine without Aura • Migraine with Aura: • Aura reversible focal neurologic symptoms that usually develop over 5-20 min and last <60 min, headache begins during aura or within 60 minutes • Visual positive / negative features • Sensory positive / negative features • Dysphasic speech

23. Question • True or False? • Migraines can be associated with autonomic and sinus symptoms • i.e. nasal congestion, rhinorrhea, tearing, colour and temperature change, changes in pupil size TRUE!

24. Question • Which of the following are associated with migraine? • Family history of migraine • Motion sickness • Obesity

25. Associated Factors • Family history and motion sickness are risk factors for developing migraine • Obesity is associated with increased frequency and severity of migraines

26. Migraine: Treatment US Headache Group: • Educate pts about condition and tx; encourage active participation in management • Use migraine specific agents in pts with severe migraine, and those who respond poorly to NSAIDs or combination analgesics • Use non-oral route for pts with sig N/V • Consider self-administered rescue meds for pts with severe migraine • Guard against medication overuse headaches by using prophylactic medication in pts with frequent headaches

27. Question • List 5 treatment options for migraine in the emergency department.

28. Treatment Options • Fluids • Analgesics: NSAIDs, acetaminophen • Serotonin Agonists • Ergotamine • DHE (Dihydroergotamine) • Triptans • Dopamine Antagonists • Chlorpromazine • Prochlorperazine • Metoclopramide • Opioids • Steroids: Dexamethasone

29. Mild Analgesics in Migraine • Some pts can get optimal response with mild analgesics (NSAIDs, acetaminophen) • Not advisable >10x /month • RCTs: Acetaminophen, ibuprofen, naproxen, diclofenac, ASA, acetaminophen + ASA + caffeine • Indomethacin: limited data, some specific migraine types are responsive to indomethacin for abortive therapy, benefit: suppository form

30. Triptans • Specific tx: 5-HT 1b/d agonist ->inhibit dural nociception • Advantage: multiple preparations • SC, IN, PO • RCT and systematic reviews: all triptans have been shown effective in acute migraine • Pts who don’t respond to one may respond to another

31. Question • So, why don’t we commonly use triptans in the ED?

32. Limitations of Triptans • More effective if used early! • Development of central sensitization • Contraindications: • Patients with pregnancy, uncontrolled htn, ischemic heart disease, peripheral vascular disease, Prinzmetal’s angina, ischemic CVA, familial hemiplegic migraine, basilar migraine • 24 hours of other 5-HT agonist (ergots), MAOIs with some triptans • Severe liver impairment • Interactions: P450 cytochrome • Advisory July 2006 – concomitant use with SSRIs or SNRIs increases risk of serotonin syndrome; advise discussion of benefit vs risk

33. Ergots: Ergotamine • Mechanism: • 5HT 1b/d receptor agonist • Efficacy: • Alone failed to show efficacy • Side effects: • Nausea, vomiting • Vascular occlusion and rebound headaches • Long-term: Associated with CAD • Avoid in pts with CAD, PVD, htn, hepatic and renal disease and those with prolonged aura European Consensus Panel: • Treatment of choice in few pts due to issues of efficacy and side effects

34. Ergots: Dihydroergotamine • Fewer side effects: no dependence or rebound headaches • Advantage: IV, IM, SC, IN use • Contraindications: • Htn, CAD, PVD, Prinzmetal’s, MAOIs, sepsis, severe hepatic or renal dysfunction, high dose ASA tx, pregnancy • Hemiplegic or basilar migraine • Within 24 hours of triptan or other serotonin agonists • CYP3A4 inhibitors: some macrolides, antifungals, protease inhibitors

35. Question • How does DHE compare to the triptans for efficacy? • More effective? • Same? • Less effective?

36. DHE: Efficacy • vs Placebo: • Proven by systematic review / RCTs, especially when given with anti-emetic • vs Triptan: • Less effective on most measures compared head-to-head with sumatriptan • vs Dopamine Antagonist: • Less effective than chlorpromazine on some measures

37. Dopamine Antagonists • Benefits: • Antiemetic • IV metoclopramide • IV or IM chlorpromazine and prochlorperazine

38. Chlorpromazine: Largactil / Thorazine Chlorpromazine 5-15mg IV or 0.1mg/kg IV • RCT vs Placebo (Bigal 2002 J Emerg Med): • Significant improvement in scores of pain, nausea, vomiting, photo/phonophobia at 60 min • NNT 2 • Side effects: • Hypotension / Postural hypotension (18%) • May be exacerbated by opioids, pre-tx with fluid bolus • Alpha-antagonist • Drowsiness • Pregnancy: Class C

39. Prochlorperazine:Stemetil, Compazine Prochlorperazine 10mg IV • Side effects: • Hypotension • Drowsiness • Dystonic Reactions • Cardiac arrhythmias • Pregnancy Class C: Isolated reports of congenital anomalies, jaundice, EPS, hyper/hyporeflexia – if occasional low-dose suggested to be safe • FDA Alert (June 2008): Association with increased mortality when used for treating dementia-related psychosis

40. Question • How does prochlorperazine compare to metoclopramide?

41. Proclorperazine vs Metoclopramide • RCT: Coppola (1995) Annals of Emerg Med • > 50% relief Stematil 82% Maxeran 48% Placebo 29% • RCT: Jones (1996) Am J of Emerg Med • Partial or complete relief Stematil 67% Maxeran 34% Placebo 16%

42. Metoclopramide: Maxeran, Reglan Maxeran 10mg IV • Efficacy: • Meta-analysis Colman (2004) BMJ • Generally poor studies • OR 2.84 for reduction of pain in headache • Less effective than chlorpromazine and prochlorperazine in relieving pain, but not always statistically significant • 1 Trial: No difference between aggressive metoclopramide (20mg IV q30 min up to 4x with diphenhydramine 25mg IV q1 hour up to 2x) vs sumatriptan 6mg SC • Benefits: • Pregnancy Class B • Can be combined with DHE, other analgesics • Side Effects: • Drowsiness • Dystonic reactions: <1-25%, increased risk in young males

43. Other Options? Some pts will not respond to routine treatment. • Consider wait-times, location (ED vs clinic) • Treat aggressively. • Do not use following meds on a chronic basis due to habit-forming nature and rebound headaches. • Benzos • Opioids • Barbiturates

44. Question • How can you prevent migraine recurrence?

45. Parenteral Dexamethasone Colman I et al. (2008) BMJ • Meta-analysis of 7 RCTs. • Dexamethasone 10-25mg IV or IM vs placebo • Similar acute pain reduction • Recurrence rates at 72 hours RR 0.74 (0.6-0.9) • NNT 9 • Similar side effect profile

46. Question • Can you name the complications of a migraine?

47. Migraine: Complications • Status migrainosus • Chronic migraine • Persistent aura without infarction • Migrainous infarction • Migraine-triggered seizure

48. Summary:Migraine Tx in the ED • Fluid bolus: NS 1L bolus IV • NSAID: If used <10x/month • Nausea / vomiting: consider PR indomethacin • PO: acetaminophen vs ibuprofen • Dopamine antagonist: • Stemetil 10mg IV • Maxeran 10mg IV (Pregnancy) • Opioid: • Morphine 2-5mg IV prn • DHE / Triptan: • If early presentation, contraindications to others • Rizatriptan, eletriptan, almotriptan • Sumatriptan: IN, SC or Zolmitriptan: IN, PO

49. Subarachnoid Hemorrhage Epidemiology • SAH 1% of all headaches in ED • 10% of hemorrhagic strokes • 10% of “worst headache ever” • Prevalence: 3-25 / 100,000 • Mean age: 55 (Range 20-60) • Reported in pediatrics Miss Rate? • Variable 5-50% (30% average) • Acceptable miss rate: 0%!

50. Question • Can you name 3 causes of SAH?