Diferencia entre revisiones de «Headache»

(Updated jolt test to correspond to meningitis page)
Línea 18: Línea 18:
# Scalp and temporal artery palpation
# Scalp and temporal artery palpation
# Sinus tap / transillumination
# Sinus tap / transillumination
#Jolt Test
# Neuro exam
##Horizontal rotation of the head at frequency of 2 rotations/second - exacerbation of pre-existing headache is positive test.
{{Jolt Test}}
##Although a 1991 study<ref>Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.</ref> showed high sensitivity for meningitis with this test, multiple newer studies have cast doubt on its sensitivity<ref>Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4</ref><ref>Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8</ref>. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% Sn
# Neuro exam


===Laboratory Tests===
===Laboratory Tests===

Revisión del 02:05 17 jul 2014

Background

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

DDx

Headache

Common

Killers

Maimers

Others

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. Neuro exam

Jolt Test

  • Horizontal rotation of the head at frequency of 2 rotations/second - exacerbation of pre-existing headache is positive test.
  • Although a 1991 study[1] showed high sensitivity with this test, multiple newer studies have cast doubt on its sensitivity[2][3]. Although it may be clinically useful in the right subset of patients, it should not be considered to be 100% Sn

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

Source

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

Annals 2008:52

  1. ↑ Jolt accentuation of headache: the most sensitive sign of CSF pleocytosis. Headache. 1991 Mar;31(3):167-71.
  2. ↑ Absence of jolt accentuation of headache cannot accurately rule out meningitis in adults. Am J Emerg Med. 2013 Nov;31(11):1601-4
  3. ↑ Jolt accentuation of headache and other clinical signs: poor predictors of meningitis in adults. Am J Emerg Med. 2014 Jan;32(1):24-8
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