The Acute Headache

1
The Acute Headache

• Devorah Nazarian, M.D.
• Mount Sinai School of Medicine
• April 12, 2002

2
Patient Presentation

• HPI-35 y.o. female presents to the E.D.
  complaining of a severe headache. The patient
  states that she was on the subway going to work,
  a few hours ago, when she suddenly felt a severe
  sharp pain in her head. Associated symptoms
  include nausea, neck pain. Patient took
  Ibuprofen prior to arrival with no relief.
• PMH- Prior history of headaches which resolve
  with ibuprofen.
• Social-Denies alcohol or cocaine. Smokes few
  cigarettes on weekends
• Meds- OCP

3
Patient Presentation continued

• P.E.-Vitals Temp 97.4 BP 122/74 HR 90 RR 16
  General appears in discomfort with eyes
  shut
  Neuro AOx3, CN II-XII intact, Motor 5/5
  throughout, nl gait, sensory grossly intact,
  reflexes equal throughout
  HEENT PERRL, EOMI, NCAT
  Neck supple, -nuchal
  rigidity
  Chest CTA-B
  Heart RRR -M
  
  Abdomen bs, soft,ND, NT
  
  Extremities FROM, -C/C/E
  Skin no rashes, no signs of trauma

4
Introduction

• 1-3 of E.D. visits are for headache.
• Only 1-5 of those patients have a serious
  underlying problem.

5
Question 1

• Does a Response To Therapy Predict The Etiology
  of an Headache?

6
Causes of a Headache

• distention, traction, or dilation of intracranial
  or extracranial arteries
• traction or displacement of large intracranial
  veins or dural envelope
• compression, spasm, inflammation, and trauma to
  cranial spinal nerves
• spasm, inflammation, and trauma to cranial
  cervical muscles
• meningeal irritation raised intracranial
  pressure
• disturbance of intracerebral serotonergic
  projections

7
Common Pathway for Pain Regardless of Underlying
Etiology of the Headache

• HA pain of the scalp and face is transmitted via
  trigeminal nerve
• Regardless of the etiology once the
  trigeminovascular axons are stimulated a pathway
  starts resulting in the onset of pain
• Serotonin receptors are the main focus of pain
  management.
• The 5-HT1 receptor is thought to be the most
  important subtype in the common pathway of
  headache

8
So What Does the Evidence Show?
9
Response of Headaches in Nonnarcotic Analgesics
Resulting in Missed Intracranial Hemorrhage

• Case series
• Presented 3 patients with headaches whose
  symptoms resolved with a variety of medications
  but returned with hemorrhage.
• Concluded that patients can have significant
  pathologic hemorrhage after successful treatment
  with nonnarcotic analgesics and release from the
  ED

Seymour JJ, Moscati RM, Jehle DV,. Response of
Headaches to Nonnarcotic Analgesics Resulting in
Missed Intracranial Hemorrhage. AM J Emerg Med .
19951343-45
10
Dihydroergotamine and Metoclopramide in the
Treatment of Organic Headache

• Case series
• Patients were given nonnarcotic agents with
  complete pain relief and found to have
  inflammatory intracranial processes.
• Using response to pain can as indicator of
  etiology may miss potential problematic headache

Gross DW, Donat JR, Boyle CA, Dihhydroergotamine
and metocloperamide in the treatment of organic
headache. Headache. 199535637-638
11
Sumatriptan Relieves Migraine-like Headaches
Associated with CO Exposure

• Case report
• One patient with a headache from CO poisoning who
  responded to sumatriptan

Lipton RB, Mazer C, Newman LC, et al. Sumatriptan
relieves migraine-like headaches associated with
carbon monoxide exposure. Headache.
199737392-395.
12
Patient Management Recommendation

• Level C Recommendation. Pain response to therapy
  should not be used as the sole diagnostic
  indicator of the underlying etiology of an acute
  headache.

13
Question 2

• Which Patients With Headache Require Neuroimaging
  
• in the ED?

14
What Is the Goal of Neuroimaging in the ED?

• To identify a treatable lesion.
• ACEP has categorized neuroimaging
• Emergent- essential for a timely decision
  regarding potentially life-threatening or
  severely disabling entities
• Urgent- arranged prior to discharge from the ED
  or, performed prior to disposition when follow-up
  cannot be assured
• Routine- indicated when the studies results are
  not considered to make a change in the patients
  disposition from the ED

15
So What Does the Evidence Show?
16
Patients With Headache and Abnormal Neurologic
Exam Require Neuroimaging

• US Headache Consortium, reviewed articles dealing
  with chronic headache
• abnormality on neurologic exam increased the
  likelihood of positive results in a neuroimaging
  by 3 fold
• normal findings in a neurologic exam reduced the
  odds of positive findings in a neuroimaging study
  by 30

US Headache Consortium. Evidence-based guidelines
in the primary care setting neuroimaging in
patients with nonacute headache. American Academy
of Neurology, 2000
17
Predictors of Intracranial Pathologic Findings in
Patients Who Seek Emergency Care Because of
Headache

• retrospective random chart review
• 468 patients who presented to the ED with chief
  complaint of headache
• abnormal findings in neurologic exam had a PPV
  for intracranial pathology of 39
• age greater than 55 was identified as clinical
  parameters associated with intracranial process
• no association found between type of HA and the
  final diagnosis

Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et
al. Predictors of intracranial pathologic
findings in patients who seek emergency care
because of Headache. Arch Neurol.
1997541506-1509
18
Practical Selection Criteria for Unenhanced
Cranial CT in Patients With Acute Headache

• retrospective review
• ED patients complaining of acute HA or acutely
  worsening HA
• 333 patients evaluated
• 17 patients had worst headache of life only
  one had positive CT results
• Does not support work-up for patients with worst
  headache
• Flawed Study

Reinus WR, Wippold FJ, Erickson KK. Practical
Selection Criteria for Unenhanced Cranial CT in
Patients With Acute Headache. Emerg Radiol.
19949467-70
19
Acute Headache of Recent Onset and Subarachnoid
Hemmorrhage

• 1 year prospective study
• acute sudden-onset HA with normal neurologic
  findings
• all patients had CT, if CT was negative LP done
• patients were followed for 3 months
• 27 patients enrolled, 9 had SAH, 1
  intraventricular hemorrhage, 1 bacterial
  meningitis, 1 with viral meningitis
• supports neuroimaging for patients with sudden
  acute onset headache

Lledo A, calandre L, Marinez-Menendez B, et al.
Acute Headache of Recent Onset and Subarachnoid
Hemmorrhage a Prospective Study. Headache.
199434172-174
20
Further Support for Neuroimaging with Severe
Headache

• Harling in a prospective study of patients
  presenting with thunderclap headache found 35/49
  to have SAH on CT or LP.
• Mills in a prospective study found that 29 of
  patients receiving head CT for worst headache of
  life had positive CT findings.
• Both studies support imaging for acute
  sudden-onset headache

Harling DW, Peatfield RC, Van Hille PT, et al
Thunderclap headache is it a migraine?
Cephalagia. 1989987-90 MillsML, Russo Ls,
Vines FS, Et al . High yield criteria for urgent
cranial CT scans. Ann Emerg Med. 1986151167-1172
21
Headache in HIV Related Disorders

• Prospective study
• 49 consecutive HIV patients with headache
• 82 had a serious identifiable cause.
• HIV positive patients with headache should be
  considered for CT and LP

Lipton RB, Feraru ER, Weiss G, et al. Headache in
HIV Related Disorders. Headache. 199131518-522
22
A Decision Guideline For ED Utilization of
Noncontrast Head CT in HIV Infected Patients

• prospective convenience sample
• 110 patients with neurologic complaints
• new seizure, depressed or altered mental status,
  and headache that was different in character or
  lasted longer than 3 days, identified all the
  cases of focal lesions in patients
• new or different HA was reported in 25 of the
  cases

Rothman RE, Keyl PM, McArthur JC, et al . A
decision guideline for the utilization of
noncontrast head CT in HIV infected patients.
Acad Emerg Med. 199961010-1019
23
Patient Management Recommendations

• Level B Recommendations. Patients presenting to
  the ED with headache and abnormal findings on
  neurologic examination should undergo emergent
  noncontrast head CT. Patients presenting with
  acute sudden-onset headache should be considered
  for emergent head CT scan. HIV positive patients
  with a new type of headache should be considered
  for urgent neuroimaging study.
• Level C Recommendations. Patients who are older
  than 50 years old with a new type of headache
  without abnormal finding on neurologic exam
  should be considered for urgent neuroimaging.

24
Question 3

• Is There a Need for Emergent Angiograghy in the
  Patient with a Thunderclap Headache Who Has
  Negative Findings In Both CT and LP?

25
Thunderclap Headaches

• sudden-onset headache of excruciating pain
  reaching its maximal intensity within a few
  seconds
• suggest presence of subarachnoid hemorrhage (SAH)
• work-up noncontrast CT and LP
• Day and Raskin presented a patient with 3
  thunderclap headaches (TCHA) in 1 week and a
  negative work-up. An angiogram showed diffuse
  vasospasm and an unruptured aneurysm.
• Could a TCHA be a sign of hemorrhage into the
  wall or rapid expansion of aneurysm.

Day JW, Raskin NH, Thunderclap Headache symptom
of unruptured aneurysm. Lancet 1986268-70
26
So What Does the Evidence Show?
27
Long-Term Follow-up of 71 PatientsWith TCHA
Mimicking SAH

• prospective follow-up study
• 71 patients who presented with TCHA with negative
  CT and LP
• followed for 3.3 years
• none developed SAH in follow-up period
• angiography is not needed in the work-up of
  patients with TCHA

Wijdicks EF, Kerkhoff H, van Gijn J, Long-term
follow-up of 71 patients with TCHA mimicking SAH.
Lancet.1988,268-70
28
Vasospasm as a cause of TCHA

• Case reports
• total of 6 patients
• angiography on all patients revealed multifocal
  segmental vasospasm without aneurysm
• vasospasm is certainly one of the causes of TCHA

Slivka A, Philbrook B, Clinical and angiographic
features of thunderclap headache.
Headache.199535,1-6 Dodick DW, Brown RD,
Britton JW, et al. Nonaneurysmal thunderclap
headache with diffuse, multifocal, segmental, and
reversible vasospasm. Cephalagia. 1999
19118-123
29
TCHA Is It a Migraine?

• prospective study
• 49 patients with TCHA, 14 patients had negative
  results
• patients followed for a minimum 18 months without
  adverse outcomes
• refutes the need for angiography in initial
  work-up of TCHA

Harling DW, Peatfield RC, Van Hille PT, et al.
Thunderclap headache is it a migraine?
Cephalagia. 1989987-90
30
The Clinical Spectrum of Unruptured Intracranial
Aneurysms

• 111 patients with unruptured aneurysms
• 54 had symptomatic aneurysms
• 8 clinical syndromes of symptomatic unruptured
  aneurysms documented
• 7 patients with TCHA
• aneurysmal mechanism of TCHA included aneurysmal
  expansion, thrombosis, and intramural hemorrhage

Raps EC, Rogers JD, GalettaSL, et al. The
clinical spectrum of unruptured intracranial
aneurysm. Arch Neurology. 199350265-268
31
Identification and Treatment of Cerebral
Aneurysms after Sentinel Headache

• case reports
• 2 patients with prolonged TCHA negative CT and LP
• angiograms showed aneurysms
• concluded that angiography needs to remain part
  of the work-up for TCHA

Hughes RL. Identification and Treatment of
Cerebral Aneurysms after Headache. Neurology.
1992421118-1119
32
Other Entities Which Can Cause a TCHA

• cerebral venous thrombosis can present TCHA
  without neurologic findings
• vertebral artery dissection and internal carotid
  artery dissection often are associated a sudden
  severe headache

33
Patient Management Recommendations

• Level C Recommendations. Patients with a
  thunderclap headache who have negative findings
  on noncontrast head CT, normal opening pressure
  and negative findings on CSF analysis do not need
  emergent angiography. These patients can be
  discharged from ED with follow-up arranged with
  their primary care provider or neurologist .