Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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
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
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 magnetic resonance imaging (MRI) Magnetic resonance angiography (MRA) Cerebral angiography
CT
Preferred in
SAH ICH
Vs
MRI
Posterior fossa lesions CVT SDH, EDH Meningeal disease Cerebritis and abscess Pituitary pathology
Frishberg 1994
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
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
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
Hemicrania Continua
Prolonged unilateral headache lasting days-weeks
Meningitis
associated with fever, neck stiffness, confusion
Cerebral tumors/abscesses
progressive headache over weeks to months
Sinusitis
overdiagnosed, dx more likely with fever/purulent nasal discharge
Trigeminal neuralgia
sharp unilateral pain usually over maxillary distribution
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