Headache HPI/Physical Exam
Concerning history: first severe headache, sudden onset (especially if during exertion (defecation, cough)), gradually worsening severe headache, different from prior headaches, occipital/posterior neck location, immunosuppressed or HIV (toxoplasmosis – CT brain lesion, crypotococcus (meningitis without fever/neck pain), lymphoma (CT brain lesion).
Medication causes: nitroglycerin, long term narcotics, MAOIs. Always ask about anticoagulants.
Physical exam: ROM of neck, tenderness in sinuses (sinusitis), temporal region (temporal arteritis), fundoscopic exam (papilledema, peripheral venous pulsation is normal and r/o ICP elevation, subhyaloid hemorrhage (looks like small blood pool from SAH).
Subarachnoid Hemorrhage: Severe and sudden onset. Non-contrast CT, then LP. CTA does not rule out bleeding. Gold standard is presence of xanthochromia in CSF.
Meningitis: Both viral and bacteria can cause headache that is rapid onset, usually accompanied by fever and meningismus (pain with neck movement, stiffness). Cryptococcal meningitis in immunosuppressed have lower onset with no fever or neck stiffness. CT does not need to be done if neuro exam intact, normal LOC, and no papilledema. Start antibiotics if LP is delayed.
Subdural hematoma: remote history of trauma with headache. Risk factors: anticoagulant use, alcohol abuse, elderly.
Brain Tumors: Only 8% have abnormal findings on neuro exam. Typical headache is worse in the morning, positional with nausea/vomiting. Can still have it evaluated in the urgent outpatient if normal neuro exam and no papilledema.
Cerebral Venous Sinus Thrombosis: Risk Factors: hypercoagulable disorders, pregnancy and peripartum, inflammatory systemic disorders, head trauma, CNS infections, medications (steroids/OCPs). Presentation: Headache, nausea/vomiting, seizures, altered mental status, focal neuro deficits. Papilledema is frequent in chronic states, not necessarily in acute presentations. Cavernous sinus thrombosis has ocular findings such as orbital pain, proptosis, and paralysis of extraocular movements (abducens is usually the first one – unable to lateral deviate the eye). Rosen’s states d-dimer can be used to rule out (elevated in 90% of cases). Best imaging study is MRI with/without contrast and MRV to detect nonvisualization of the same vessel.
Temporal Arteritis: Gotta be over >50 years old, more common in women. Temple, jaw claudication, hx/o polymyalgia rheumatic. Most serious complication is vision loss, due to ischemic optic neuritis. Normal ESR rules out. If suspected highly, need to start prednisone to prevent vision loss (40-60mg prednisone daily).
Sinusitis: Headache varies with head position. Colored nasal discharge, maxillary toothache, decongestant not working. Frontal sinusitis over forehead, maxillary over cheeks, ethmoid sinusitis behind and between eyes, and sphenoid causes diffuse headache.
Idiopathic Intracranial Hypertension: Risk Factors: Young, obese women of child-bearing age (though obese people generally have higher ICP anyway). Use of oral contraceptives, anabolic steroids, tetracyclines, vitamin A. Features: Generalized gradual headache with moderate intensity. May be worse with eye movement. Exacerbated by bending forward and the Valsalva maneuver. Visual complaints: transient obscuration periodically with episodes of prolonged periods of visual loss. Can also complain of nausea/vomiting/dizziness. Can have CN VI nerve palsy (Abducens – unable to deviate laterally). Usually will reveal papilledema and visual field defects. Pulsatile tinnitus. Criteria: Normal alert patient with normal neuro exam or can have papilledema, enlarged blind spot, or visual field defect. Increased CSF pressure (>200 mm H20 in non obese, >250 in obese). Fulminant IIH: VISION LOSS, severe papilledema. No papilledema? Rare, and the few case reports have intractable headaches. Typically not at risk for vision loss. (per UpToDate). MRI findings: flattening of the sclera (80%), distension of perioptic subarachnoid space (50%), empty sella (70%). UpToDate recommends MRI/MRV to rule out cerebral venous thrombosis as well since their symptoms are very similar. Treatment: Lowering ICP with LP. Acetazolamide (Diamox, 250mg BID) or Topamax (carbonic anhydrase inhibitor) can decrease CSF production or with a loop diuretic. In patients with impending visual loss, placement of VP shunt or optic nerve sheath fenestration.
Cervical Artery Dissection: spontaneous or result of trauma. Usually younger (<40yo). Internal carotid is unilateral anterior neck with headache around eye or frontal area. Present or eventually develop neuro signs (TIA, stroke, Horners, transient monocular blindness, or CN palsies). Diagnosis with CTA. Anticoagulation is treatment, but make sure theres no overlying SAH as well.
Post-LP Headache: Occurs in 10-40% within 24-48 hrs after. Caused by persistent CSF leak. Worse with upright position, relief with laying flat. Treat with simple analgesics, IV fluids, IV caffeine. Blood patch may be required if all other modalities fail.
Migraine: slow onset, lasting 4-72 hours, unilateral and pulsating. Visual auras causes scintillating scotomata (dark spot) or flashing lights, but virtually any neuro deficits can occur. Ophthalmoplegic migraine: headache with paresis or CN III, IV, or VI or retinal migraine: monocular blindness with headache. Treatment: DHE/dihydroergotamine is serotonin 1B/1D agonist: 1mg IV over 3 min, pretreat with reglan or other nausea medication. CI: pregnancy, uncontrolled HTN, CAD, recent sumatriptan use. Triptans/sumatriptan are more selective and cause less N/V, though cause more other SEs including tingling/chest pain, and has higher relapse than just DHE. Reglan/metoclopromide 10mg IV is Pregnancy Class B, may cause dystonic reaction (diphenhydramine/benadryl as adjunct with treatment). Ketorolac 30mg IV unless PUD hx, third trimester pregnancy. Olanzapine/Zyprexa 10mg IM has been used an alternative to droperidol. Dexamethasone 10mg IV can reduce rate of recurrence.
Tension Headache: bilateral, non pulsating, though can be just the same as migraine. Treatment basically the same as migraine.
Cluster Headache: rare, short-lived, more common in men, usually start after 20yo. Unilateral orbital (trigeminal distribution) lasting 15-180 minutes. Occurs in clusters, treatment with high flow oxygen can help as well as DHE/sumatriptans. Associated signs: conjunctival injection, lacrimation, nasal congestion, facial swelling, mitosis, ptosis.
Trigeminal Neuralgia: paroxysms of severe unilateral pain in trigeminal nerve lasting only a few seconds. Carbamazepine/Tegretol started at 100mg PO BID and then increased in dosage as needed is effective. If not working, then likely isn’t TN.
Idiopathic Intracranial Hypertension…Everything you Need to Know in the ED – Chandra Aubin – 25 min video
UpToDate, IIH: Clinical features and Diagnosis
Tintinalli, Chapter 159: Headache and Facial Pain