Diferencia entre revisiones de «Headache»

(Created page with "==Background== -DHE & triptans contraindicated w/ HTN, CAD, or pregnant (not as effective as compazine) -HIV pts: india ink & cryptococcal antigen (CD4 >200 --> toxo & crypto ...")
 
Sin resumen de edición
Línea 1: Línea 1:
==Background==
==Pearls==




-DHE & triptans contraindicated w/ HTN, CAD, or pregnant (not as effective as compazine)
- Opening pressure useful for SAH, cerebral venous thrombosis


-HIV pts: india ink & cryptococcal antigen (CD4 >200 --> toxo & crypto unlikely)
- LP is required if suspect SAH
 
-NO correlation w/ elevated BP causing HA
 
 
==Diagnosis==
 
 
===CT Sensitivity for SAH===
 
 
Acute ~93%
>12hrs ~83%
>3days ~73%
*Need to LP
 
== ==
 
 
==DDx==
 
 
===Common===
 
 
Migraine
 
Tension
 
Cluster  (O2 for 15 min)
 
 
===Killers===
 
 
Meningitis/encephalitis  ("jolt test" 100% sens)
 
SAH (xanthochromia>6hrs)
 
ICH (subdura/epidural)
 
Acute obstructive hydrocephalus
 
Space occupying lesions
 
Stroke
 
Depression
 
Carbon monoxide poisoning
 
Basilar artery dissection
 
Preeclampsia
 
Cerebral Venous Thrombosis (pregnancy & post-partum)
 
Hypertensive Emergency


   
   


===Maimers===
===History===
 
 
Temporal Arteritis  (>50 yrs &  ESR)
 
Idiopathic intracranial hypertension
 
Acute glaucoma (decreased vision)


Acute sinusitis


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


===Others===
Physical Exam
 
 
Trigeminal neuralgia
 
Temporomandibular
 
Post LP/ low CSF
 
Dehydration
 
Analgesia abuse
 
Eye, dental, or derm cause
 
Febrile HA


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


===Red Flags===
===Laboratory Tests===




Sudden onset or accelerating pattern
* If suspect temporal arteritis -> ESR
 
* If suspect meningitis -> CSF studies
No similar headache in past
* Cannot use CBC to rule-out meningitis!
 
* Add India Ink, cryptococcal antigen if suspect AIDS-related infection
Age > 50 years
* If suspect CO poisoning -> carboxyhemoglobin level
 
Occipitonuchal HA
 
Visual disturbances
 
Exertional
 
Family history of SAH
 
Focal neurologic signs
 
Diastolic BP > 120
 
Papilledema
 
Jaw claudication
 
   
   


Headache in setting of:
===Imaging===
 
1. Infection
 
2. Cancer
 
3. Immunosuppression
 
4. Syncope
 
5. Trauma
 
6. Altered mental status
 
7. Systemic illness (fever, stiff neck, rash)


8. Nausea/vomiting
7. Patient on anticoagulation, steroids, NSAIDs


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


NEUROIMAGING RECOMMENDED: (non-con head CT)
Treatment


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


Headache and New Neurologic Deficit
===See Also:===
 
New, sudden onset, severe HA


HIV positive patient with new type of headache


Patients > 50 y.o. with new type of headache (urgent, within 72 hours)
===Headache DDX===




Class B recommendations
=== Headache Red Flags  ===


==Treatment==


===CT Before LP===


===ED===


== ==


1. Compazine 10mg IV (+\- benadryl)
2. DHE 1mg IV (contra inc in preg, CV risk, motor prodrome)
or sumatriptan (expensive)
3. Morphine
4. NS
===Out-pt===
Mild
NSAIDS/Ergots (+/- mag, riboflavin)
Mod (~1/wk)
give sumatriptam for breakthrough
Severe (>1/wk)
propy = b-blocker


==Source==
Source


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


7/2/09 PANI  from Annals 2008:52.
Annals 2008:52




Revisión del 23:40 1 mar 2011

Pearls

- Opening pressure useful for SAH, cerebral venous thrombosis

- LP is required if suspect SAH


History

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


Physical Exam

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


Laboratory Tests

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


Imaging

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


Treatment

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


See Also:

Headache DDX

Headache Red Flags

CT Before LP

Source

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

Annals 2008:52

Obtenido de «https://www.wikem.org/w/index.php?title=Headache&oldid=659»