Headache

Background

1. Opening pressure useful for SAH, cerebral venous thrombosis
2. LP is required if suspect SAH

Diagnosis

History

1. Time to maximal onset
2. Location
   1. Occipital - Cerebellar lesion, muscle spasm, cervical radiculopathy
   2. Orbital - Optic neuritis, cavernous sinus thrombosis
   3. Facial - Sinusitis, carotid artery dissection
3. Prior headache history

Physical Exam

1. Scalp and temporal artery palpation
2. Sinus tap / transillumination
3. Jolt test (have pt rapidly shake head side to side)
   1. 100% sensitive for meningitis
   2. "Most useful adjunctive maneuver for evaluating headache in the presence of fever"
4. Neuro exam

Laboratory Tests

1. If suspect temporal arteritis -> ESR
2. If suspect meningitis -> CSF studies
   1. Cannot use CBC to rule-out meningitis!
   2. Add India Ink, cryptococcal antigen if suspect AIDS-related infection
3. If suspect CO poisoning -> carboxyhemoglobin level

Imaging

1. Consider non-contrast head CT in patients with:
   1. Thunderclap headache
   2. Worst headache
   3. Different headache from usual
   4. Meningeal signs
   5. Headache + intractable vomiting
   6. New-onset headache in pts with:
      1. Age > 50yrs
      2. Malignancy
      3. HIV
      4. Neurological deficits (other than migraine with aura)
   7. Consider CXR
      1. 50% of pts w/ pneumococcal meningitis have e/o PNA on CXR

Treatment

1. Migraine
   1. 1st line: Prochlorperazine (compazine) 10mg IV (+/- benadryl)
      1. Most effective therapy
   2. 2nd line:
      1. Metoclopramide (reglan) 10mg IV
      2. DHE 1mg IV (often used with an antiemetic)
         1. Contraindications: pregnancy, cardiovascular disease, HTN
      3. Triptans
         1. Contraindications: cardiovascular disease
   3. Ketorolac
2. Cluster
   1. Oxygen
   2. Triptans
   3. DHE
   4. Corticosteroids
   5. Verapemil
3. Tension
   1. NSAIDs

See Also

Headache DDX

Headache Red Flags

CT Before LP

Source

EB Medicine, 06/01, vol 3, number 6

Annals 2008:52