Headache

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

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 30^o (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:

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