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)