Differential Diagnosis
- Vascular: bleed (epidural, subdural, subarachnoid, intraparenchymal), clot (venous sinus thrombosis), spasm (migraine), HTN
- Infectious: meningitis, encephalitis, sinusitis, mastoiditis, dental, intracranial abscesses
- Neoplasm and increased ICP (pseudotumor cerebri)
- Drugs
- Inflammatory: temporal arteritis, vasculitides
- Congenital
- Autoimmune
- Trauma
- Endocrine
- Other
- Ocular: glaucoma, optic neuritis
- MSK: TMJ syndrome, tension-type, C-spine disorders
- Cranial neuralgias
- Carbon monoxide exposure
Deadly (or blinding) headaches
- Meningitis
- Subarachnoid hemorrhage
- Venous sinus thrombosis
- Temporal arteritis
- Acute angle closure glaucoma
Migraines
- Onset
- Females – biphasic onset: late teens, late 40s
- Males – biphasic onset: early childhood, 20s
- Presentation
- 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, allergies
- Food (nitrates, chocolate, caffeine)
- EtOH
- Smoking
- Menses
- Weather
- Lack of sleep
- Treatment
- ABC’s
- Dark quiet room
- Fluids
- Abortive therapy
- Metoclopramide 10-20mg IV
- NSAIDS
- DHE 0.5 mg IV given over 2-3 minutes (following Maxeran and fluid bolus – contraindicated if use of triptans w/i 24hr, heart disease or HTN, pregnancy)
- Prochlorperazine (Stemetil) 10mg IV
- Chlorpromazine (Largactil) 0.1-0.2mg/kg IV with NS bolus
- Rescue pain
- Meperidine 75-100mg IM with antiemetic
- Morphine 7.5-10mg IM with antiemetic
- Codeine, oxycodone
- ASA, Tylenol, Ibuprofen
- Prophylaxis
- Beta blockers or CCB
- Tricyclics
- Triptans
Assessment of potential bleeds
- ABCs
- Intubate a GCS ≤ 8
- IV access, O2
- C-spine precautions if traumatic
- Standard labs
- Monitor neurovitals and vitals
- Emergent CT without contrast (95% sensitive of SAH at 24hr… 50% by 1 wk)
- LP (xanthochromia = SAH; RBCs)
- Hx – sentinel bleed in prior 2-3wks (SAH)
- NeuroSx consult
- Bedrest, elevate head of bed 30o (risk of re-bleed greatest in 24hr)
- Control pain and vomiting (especially)
- Rx
- Antiemetics
- Antivasospam agents
- Seizure prophylaxis
- Antihypertensives
Subdural hematomas: tearing of the bridging veins between the cortex and the dural sinuses (elderly and alcoholics)
Acute Presentation:
- Level of consciousness: altered or deterioration – may have a lucid interval
- Common symptom: headache, vomiting, lethargy
- Unilateral weakness – use pronator drift to assess
- Pupils: asymmetry is a late finding (note: hematoma will be on same side as dilated pupil)
Sub acute/Chronic Presentation:
- Headaches, worsened by changing position
- Cognitive or personality changes
- New onset of seizures
- New hemiparesis or weakness
Acute subdural: diagnosed within 5 days and hyperdense on CT
Sub-acute subdural: diagnosed between 5 and 21 days and is isodense then hypodense on CT
Chronic subdural: diagnosed after 21 days, hypodense on CT
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Best Regards.