Headaches

Always ask:

  • Is this the worst headache of your life?
  • Onset (acute/gradual)
  • Positional component
  • Nausea, vomiting, photophobia, sonophobia
  • Neurological phenomena
  • Previous headaches (is this similar)

90% are tension or migraine

Sporadic – migraine (letdown HA – i.e. every Saturday)
Everyday, continuous (or 3-4x/week) – tension
Many HA/d x 3 weeks, then gone then returns a few years later again – cluster

Always get:

  • History (Past medical history, Past surgical history, Social history, Medications, Allergies) and Physical exam
  • CT head
  • CBC and diff.

Migraine:

  • Females – biphasic onset: late teens, late 40s
  • Males – biphasic onset: early childhood, 20s
  • Classic: with aura (scintillating scotoma – wavy lines, flashing lights, expanding blind spot) lasting ~30 minutes
  • Common: without aura
    • Unilateral (sometimes bifrontal) – esp. at onset
    • Pounding/throbbing
    • Photophobia and/or sonophobia
    • Nausea and/or vomiting
    • No positional component
    • Usually lasts until patient falls asleep (hrs – day)
  • Triggers
    • Stress
    • Food (nitrates, chocolate, caffeine)
    • Alcohol
    • Smoking
    • Menses
    • Weather
    • Allergies
    • Lack of sleep
  • Treatment: Abortive vs Preventative
    • 1st line – Ibuprofen 600mg
    • IV fluid and maxeran
    • Triptans
    • Demerol, DHE (ergot)
    • Prevent with Beta Blockers (or CCB)



 

Tension:

  • Female, mid aged
  • Gradual onset
  • “Band-like”, into neck and shoulders
  • Positional component (worse with head/neck movement)
  • Treatment:
    • Antiinflammatories
    • Muscle relaxants (Flexeril)

Cluster:

  • Acute onset
  • Male, young
  • Retro-ocular
  • Multiple/day
  • May have red, watery eye
  • Treatment: CCB (but difficult)

Meningitis:

  • Immune-suppressed, young adults, children
  • Occipital and into neck
  • Nausea and vomiting
  • Fever
  • Positional possible
  • Meningismus (Kernig and Brudzinski signs)
  • Ask about: immunization, exposure, recent infections
  • LP: Rule out increased ICP (papilledema, CT head)
    • Tube #1 – CBC
    • #2 – protein and glucose
    • #3 – gram stain and sensitivity
    • #4 – CBC (bloody tap), viral PCR (herpes)
  • Treatment: antibiotics (empiric!)

Subarachnoid hemorrhage:

  • Sudden onset
  • Worst headache of life
  • Risk factor: Hyptertension!
  • Nausea (blood is an irritant to brain, meninges)
  • Vomiting
  • Isolated neurological symptoms (i.e. anterior inferior surface – 3rd CN palsy)
  • Positional (better sitting b/c of increased ICP from blood)
  • Treatment: admit and do serial CT scans; control BP <180/110

Increased ICP:

  • Pseudotumor cerebri (positional, nausea)
  • Tumor (neurological phenomena, positional)

Decreased ICP:

  • i.e Post LP
  • Positional

Headaches that KILL

  • Meningitis
  • Subarachnoid hemorrhage
  • Temporal arteritis
  • Acute angle closure glaucoma
  • Venous sinus thrombosis (young females, clot in venous sinus)

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