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Acute Headache An Overview

DR SHALIN SHAH MD, DM Neurology SGPGI, Lucknow

Most of the time he seemed to see something shining before him like a light, usually in part of the right eye; at the end of a moment, a violent pain supervened in the right temple, then all of the head and neck, where the head is attached to the spinevomiting, when it became possible, was able to divert the pain and render it more moderate.
Hippocrates

The Burden of Headache


4% of visits to the physicians office 1-2% of visits to the emergency department Lifetime prevalence for any type of headache > 90% for men & 95% for women Most have primary headache disorders In patients with the worst ever headache of their life, and normal neurological exam, 12% will have SAH

Working classification of headache


Primary Headache Migraine (10% prevalence) Tension-type headache(30-80% prevalence) (CTH-2%) Cluster headaches
Secondary Headache

Secondary headache disorders


Vascular Disorder - Stroke, SAH Tumour Trauma Infection Temporal arteritis Ophthalmological (glucoma) and ENT causes. Systemic disorders- thyroid disease, HT, pheochromocytoma

Danger signals
First or worst headaches Headache on exertion, early morning, or nocturnal Progressive headache New onset headache in adult >50 years old Abnormal physical or neurological findings (fever, stiff neck)

History
Onset /Duration/Progress Age of onset
> 50 years

Headache characteristics
Precipitating/Reliving factors Quality Region Severity (0-10) Timing

Past history of headaches


first, worst, different, progressive, persistent

History
Associated Symptoms
Fever/Chills/Nightsweats Nausea/Vomiting Photophobia & Phonophobia Neck pain or stiffness Alterations in level of consciousness Focal neurologic symptoms

Family History

Physical Examination
General Exam
Vital Signs / HEENT (Trauma, dentition, sinus/temples) Neck /Skin /Lymph Nodes

Neurologic Exam
Mental Status: LOC, Orientation,Language,mood Cranial Nerves-Fundus, EOM, V,VII Motor / Sensory/ Reflex/Gait

Subhyaloid hemorrhage

Laboratory Studies
Blood
CBC Chemistry panel ESR PT/PTT (Consider hypercoagulable profile) TSH ABG (if clinically indicated) Drug screen

Urinalysis

Imaging
X-rays
CXR Cervical Spine X-ray

Cranial computed tomography (CT)


preferred initial imaging study for acute headache

Cranial magnetic resonance imaging (MRI) Magnetic resonance angiography (MRA) Cerebral angiography

Indications for neuroimaging


First or worst headache Progressive or CDH Side-locked headache Headaches not responding to treatment New onset headache in patients with cancer, HIV infection, or age >50 yrs Associated fever, stiff neck, neurological deficits

CT
Preferred in
SAH ICH

Vs

MRI
Posterior fossa lesions CVT SDH, EDH Meningeal disease Cerebritis and abscess Pituitary pathology

Imaging in pts with headache and normal neurological exam


BenefitsCT Migraine 0.3% Any HA 2.4% Relief of anxiety 30% Harms-iodine reaction Mild 10% Death 0.002% Claustrophobia Cost MRI 0.4% 2.4%

Frishberg 1994

Probability of detection of SAH on CT after the initial event


Day 0 Day 3 1 week 2 weeks 3 weeks 95% 75% 50% 30% almost 0%
Evans RW 1999

Other Studies
Lumbar puncture (LP)
indicated if acute or chronic meningitis, SAH, pseudotumor cerebri (IIT) or low CSF pressure headache suspected preferable to perform CT before LP

Electroencephalogram (EEG)
indicated if seizures are suspect

Angiography
In proven SAH- 4 vessel angio(DSA) to identify source and r/o multiple aneurysms Initial arteriogram negative in upto 16% of SAH MRA detects 90% of saccular aneurysms of >5mm Spiral CT angio detects 85% of saccular aneurysms

Differential Diagnosis
Primary headache
Migraine Tension-type headache Cluster headache Indomethacin-responsive headache syndromes

Secondary headache

Migraine Headache
IHS Classification
Migraine without aura (common migraine) Migraine with aura (classic migraine)
Migraine with typical aura Migraine with prolonged aura Familial hemiplegic migraine Basilar migraine Migraine aura w/o headache Migraine with acute onset aura

Opthalmoplegic migraine Retinal migraine

Acute Treatment
Mild - NSAID+Anti emetic Moderate NSAID/Ergot/TriptanSumatriptan/Rizatriptan + Anti emetic Severe Ergot +Antiemetic (rectal), Sumatriptan-nasal/Subcu ,Rizatriptan oral Very severe- Ketorolac IM /DHE IV +Antiemetics, Opiods

Preventive Treatment
Proven or well accepted B Blockers-Propanolol, metoprolol Amitryptyline / Divalproex / Flunarizine / Methysergide. Widely used with poor evidence Verapamil/SSRI Promising Topiramate/Gabapentin

Tension-type headache
IHS Classification

Episodic Tension-type headache Chronic (Daily) Tension-type headache

Cluster Headache
IHS Classification
5 or more attacks with the following:
Severe unilateral supraorbital or temporal pain lasting 15-180 minutes, pain has boring quality One of the following ipsilateral autonomic signs
conjunctival injection eyelid edema tearing nasal congestion/rhinorrhea forehead/facial sweating

miosis or ptosis

Frequency of attacks qod to 8x/day, occur at similar time of day and often awaken pt from sleep

Indomethacin-Responsive Headache Syndromes


Paroxymal Hemicrania
Onset second-third decade Females > males (3:1) Unilateral orbit or occipital pain 20 minute attacks, 5 attacks/day on average

Hemicrania Continua
Prolonged unilateral headache lasting days-weeks

Secondary Headache DDx


Subarachnoid Hemorrhage (SAH)
first or worst headache
Chance of misdiagnose in SAH high pts with the greatest potential tx benefits are most often misdiagnosed early complications develop in patients with an incorrect dx

Meningitis
associated with fever, neck stiffness, confusion

Secondary Headache DDx


Subdural hematoma
recent trauma (+/-)

Stroke (Ischemic or Hemorrhagic)


occurs with focal neurologic sx

Cervicocephalic arterial dissection


trauma hx (+/-), neck pain, ipsilateral Horners

Giant cell arteritis


> 50 yrs, visual loss, temporal pain, ESR

Secondary Headache DDx


Cerebral venous thrombosis
diffuse headache from increased ICP, may see sz or focal neurologic symptoms

Idiopathic intracranial hypertension


young obese women, blindness may develop

Unruptured vascular malformation (AVM)


can result in migraine like headaches

Cerebral tumors/abscesses
progressive headache over weeks to months

Secondary Headache DDx


Dental: abscesses/TMJ
oral or jaw pain initially

Sinusitis
overdiagnosed, dx more likely with fever/purulent nasal discharge

Trigeminal neuralgia
sharp unilateral pain usually over maxillary distribution

Low CSF pressure headache


sx resolve in supine position and recur when upright

Acute Glaucoma
periorbital pain, conjuntival injection, lens clouding

Case Study #1
28 year-old female presents with acute headache since 4 days and one episode of confusional state 2days back.On examination no focal deficit.History of episodic headaches that occur four to five times a month since 4 years. Have since increased in severity. The headache itself in usually on the left side, throbbing in nature and severe. It lasts 4-6 hours. CT Brain /CSF done. Persistent headache.Next day MR angio done

Case Study #2
42 year-old femalepresented with history of acute very severe headache since 2 days. Associated with nausea and photo/phonophobia.No significant past history.Physical examination including fundus normal. Patient CT Brain was done. Treated with analgesics,beta blockers and flunarizine.No response. Was given suatriptan nasal spray. Patient felt better for 24 hours.Again patient had severe headache.

Case Study #3
78 year-old female presented with acute right frontaltemporal headaches associated with nausea and vomiting. H/O similar headache 4 months back for 1 day. She was HT with h/o CV stroke 2 years back. Neurologic examination normal except bilateral diminished vision due to mature cataract.

Thank You

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