Headache
Background
-DHE & triptans contraindicated w/ HTN, CAD, or pregnant (not as effective as compazine)
-HIV pts: india ink & cryptococcal antigen (CD4 >200 --> toxo & crypto unlikely)
-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
Temporal Arteritis (>50 yrs & ESR)
Idiopathic intracranial hypertension
Acute glaucoma (decreased vision)
Acute sinusitis
Others
Trigeminal neuralgia
Temporomandibular
Post LP/ low CSF
Dehydration
Analgesia abuse
Eye, dental, or derm cause
Febrile HA
Red Flags
Sudden onset or accelerating pattern
No similar headache in past
Age > 50 years
Occipitonuchal HA
Visual disturbances
Exertional
Family history of SAH
Focal neurologic signs
Diastolic BP > 120
Papilledema
Jaw claudication
Headache in setting of:
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
NEUROIMAGING RECOMMENDED: (non-con head CT)
Headache and New Neurologic Deficit
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)
Class B recommendations
Treatment
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
7/2/09 PANI from Annals 2008:52.