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

Source

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

Annals 2008:52