Headache

Background

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

DDx

Headache

Common

• Migraine headache
• Tension headache
• Cluster headache

Killers

• Meningitis/encephalitis
  • Neoplastic meningitis
• Myocardial ischemia
• Retropharyngeal abscess
• Intracranial Hemorrhage (ICH)
  • SAH / sentinel bleed
• Acute obstructive hydrocephalus
• Space occupying lesions
• CVA
• Carbon monoxide poisoning
• Basilar artery dissection
• Preeclampsia
• Cerebral venous thrombosis
• Hypertensive emergency
• Depression

Maimers

• Giant cell arteritis of temporal artery (temporal arteritis)
• Idiopathic intracranial hypertension (Pseudotumor Cerebri)
• Acute Glaucoma
• Acute sinusitis
• Cavernous sinus thrombosis or cerebral sinus thrombosis
• Carotid artery dissection

Others

• Mild traumatic brain injury
• Trigeminal neuralgia
• TMJ pain
• Post-lumbar puncture headache
• Dehydration
• Analgesia abuse
• Various ocular and dental problems
• Herpes zoster ophthalmicus
• Herpes zoster oticus
• Cryptococcosis
• Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
• Ophthalmoplegic migraine
• Superior Vena Cava Syndrome

Aseptic Meningitis

• Viral
  • Varicella
  • Herpes
  • Enterovirus
  • West Nile
• Tuberculosis
• Lyme disease
• Syphilis
• Leptospirosis
• Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
• Noninfectious
  • Sarcoidosis
  • Vasculitis
  • Connective tissue disease
  • Drug induced aseptic meningitis

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

• Tension Headache
• Migraine Headache
• Cluster Headache
• Headache Red Flags
• CT Before LP

Source

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

Annals 2008:52