Episode 16 – Headaches

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

This week we review a post from Dr. Rob Orman’s ERCast, Is it really a sinus headache?

POUND- 4 criteria is very indicative of migraine (+LR 24), 3 criteria also likely (+LR 3), although most of this comes from the outpatient literature [1].

  • Pounding headache
  • hOurs: headache lasts 4-72 h without medication
  • Unilateral headaches
  • Nausea
  • Disabling: disrupts daily activities

The Bread and Butter

We summarize some key topics from the following readings, Tintinalli (7e) Chapter 159 ; Rosen’s 8(e) Chapter 20, 103 – but, the point isn’t to just take our word for it.  Go enrich your fundamental understanding yourself!

In Emergency Medicine, our job is to investigate and think about the life and limb threatening causes, even to mundane problems.   Things such as intracranial bleeds, meningitis, masses – these are huge deals and are covered well and hammered into our heads.  For FOAM core content on this, check out the St. Emlyn’s podcast.  On this episode, we’re running a mini-ophthalmology headache special and focusing on headaches that treatment may render “sight saving.”

Temporal Arteritis – often in patients older than 50 years of age and more common in those with a history of polymyalgia rheumatica. May be accompanied by visual changes including the “classic” amaurosis fugax or “curtain” of unilateral vision loss.  If not treated, these patient can lose vision permanently.

  • Unilateral or localized headache, often in the temporal or retro-orbital area
  • Jaw claudication (pain with chewing) – most specific sign
  • Decreased pulse in temporal artery or tenderness
  • Sedimentation Rate (ESR) >50

Treatment

  • Prednisone 40-60 mg if thinking about diagnosis
  • Temporal artery biopsy within 48 hrs

Acute Angle Closure Glaucoma – Classically, these patients present with unilateral mid-dilated pupils and severe nausea, vomiting, and headaches.  The history can, naturally, be less classic and more vague.  Also, if not treated, this can lead to vision loss.

  • Elevated intraocular pressure (>20 mmHg)
  • Decreased visual acuity
  • Fixed irregular semidilated (midposition) pupil
  • Slit lamp — shallow AC (closed angle), injected conjunctiva; corneal microcystic edema (cloudy)

Treatment –

  • Ophthalmology consult stat
    • They may want topical b-blocker, cholinergic, alpha-2 agonist, eye drops or administration of acetazolamide

Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) – Common in young, overweight women or those on oral contraceptives.  Untreated, they can suffer vision loss.

  • Elevated opening pressure (>20-25 cm H20) on lumbar puncture

Treatment

  • Neuro follow up
  • Acetazolamide +/- furosemide
  • Therapeutic lumbar punctures

Cerebral Venous Sinus Thrombosis – may present as atypical headache with stroke like symptoms in patients without known vascular risk factors.  The neurological findings may be transient.  Often associated with post-partum patients, patients with hypercoaguable states (Factor V mutations, protein C or S deficiency, antithrombin III deficiency, etc), patients on OCPs.

Diagnosis – CTV or MRV (magnetic resonance venography) after CT scan, which may be normal.

Treatment – Anticoagulation, although this is somewhat controversial

Generously Donated Rosh Review Questions (Scroll for Answers)
Question 1. A 73-year-old woman with a history of hypertension presents with a unilateral headache for 3 weeks. She states that she has a throbbing pain at her right temple and has pain in her jaw with opening and closing. The vision in her right eye has worsened over the previous day. Her blood pressure is 173/100.
 [polldaddy poll=8340282]
Question 2. A 71-year-old woman presents to the ED with daily headaches for 2 months. She describes the headache as a dull pain that is most intense in the morning and resolves by the afternoon. On exam you note 4/5 motor weakness of the left upper and lower extremity.
[polldaddy poll=8340292]
References:
1. Detsky ME,McDonald DR, Baerlocher MO, Tomlinson GA,McCrory DC, Booth CM. Does this patient with headache have a migraine or need neuroimaging? JAMA. 2006 Sep 13;296(10):1274-83.

2. Chapter 20, 103.  Rosen’s Emergency Medicine, 8e.

3.Chapter 159.  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011

Answers
1. D. This patient presents with a unilateral, subacute headache with associated jaw claudication and vision change; symptoms consistent with temporal arteritis. Temporal arteritis or giant cell arteritis is a systemic inflammatory process of small and medium-size arteries. The most commonly involved vessels are the ophthalmic vessels and the extracranial branches of the aortic arch. The disease typically affects patients over 70 years of age and is more common in women than in men. Patients present with a subacute headache that is throbbing in nature and may be present for weeks to months. Often, patients will have symptoms for more than 2 months. Patients may also report jaw claudication secondary to vascular insufficiency of the masseter and temporalis muscles. Physical examination may reveal tenderness over the temporal artery. Systemic symptoms may also be present including fever, joint pains, and weight loss. Diagnostic testing in the Emergency Department generally begins with an erythrocyte sedimentation rate (ESR) with a cutoff of 50 mm/hour although the level may be >100 mm/hour. However, the ESR will be normal in 10-25% of patients. The gold standard diagnostic test is a temporal artery biopsy. In patients with a high-clinical likelihood of temporal arteritis, treatment should be initiated regardless of initial diagnostic testing as delay can lead to permanent visual loss. Prednisone should be started at 60 – 120 mg/day.

Carbamazepine (A) is the treatment of choice for trigeminal neuralgia, not temporal arteritis. The patient does not present with symptoms consistent with hypertensive emergency requiring emergent antihypertensive treatment withlabetalol (B). A non-contrast head CT scan (C) is not helpful in temporal arteritis as the disease does not involve the intracranial contents.

2.  B  More than half of patients diagnosed with a brain tumor complain of headache. However, the headache associated with brain tumor is highly variable. Patients may describe it as continuous or intermittent, unilateral or bilateral, sharp or dull. It is associated with neurologic deficits less than 10% of the time. However, in the setting of aneurologic deficit and chronic headache (as in this scenario with motor weakness), a mass lesion should be strongly considered as the cause. Patients may also complain of nausea, vomiting, visual change, and gait disturbance. Headaches due to brain tumors are classically associated with pain that is worse in the morning (as in this case). However, this is rare.

Central venous thrombosis (A) results from hypercoagulable states and is associated with acute to subacute headaches with vomiting and sometimes seizures. Risk factors include the use of oral contraceptives, postpartum or postoperative states, and any hypercoagulable state such as factor V Leiden mutation, antithrombin III deficiency, protein S or C deficiency, or polycythemia. The diagnosis is usually made by MRI venogram. Migraine headache (C) is classified as a primary headache and can be quite variable in presentation. These headaches can be associated with nausea, vomiting, photophobia, and phonophobia. The headache may also be preceded or accompanied by an aura that develops gradually over minutes, usually lasts 60 minutes, and is reversible. Auras may include neurologic symptom but commonly include scintillating scotomas (dark spots) or flashing lights. Temporal arteritis (D) occurs almost exclusively in patients older than 50 years and is much more common in women. Headache is the most common symptom of temporal arteritis and usually occurs over the frontotemporal region. It is strongly associated with a history of polymyalgia rheumatic. It is not associated with focal neurologic deficits, but it can lead to vision loss due to ischemic optic neuritis.

Episode 5 – Psychiatry and Increased ICP

Episode 5 – Psychiatry & Increased Intracranial Pressure (iTunes or Listen Here

The Free Open Access Medical Education (FOAM)

Academic Life in Emergency Medicine -Atypical Antipsychotic Medication Re-initiation in the Emergency Department

  • Determine how long the patient has been without their atypical antipsychotic.
  • Consider dosing reductions in patients who have been without their medications for more than a few doses or in patients at higher doses.
  • Look up the recommendations.

Broome Docs – Optic Nerve Sheath Diameter (ONSD) – helpful and interesting for gauging increased ICP, but probably not quite ready for prime time.

  • ONSD under 5 mm, ICP is probably OK
  • ONSD over 6 mm, ICP is probably not OK
  • ONSD 5-6 mm utility is uncertain

The Bread and Butter

We summarize some key topics from the following readings,  Tintinalli (7e) Chapters 284, 254 ; Rosen’s (8e) Chapters 110, 29 …but, the point isn’t to just take our word for it.  Go enrich your fundamental understanding yourself!

Psych Pearls

The 1st generation antipsychotics treat the positive psychotic features

  • Hallucinations, delusions, disorganized speech, disorganized behavior

The 2nd generation antipsychotics treat  the negative psychotic features

  • Blunted affect, emotional withdrawal

Brief psychotic disorder vs schizophrenia

  • Brief psychotic disorder is the sudden onset of psychotic symptoms in response to major stress and lasts several days to 1 month (<1 month)
  • Schizophreniform is 1-6months
    •  ⅓ of pts with schizophreniform recover, ⅔ don’t and develop schizophrenia.
  • Schizophrenia is > 6 monthst.

Consider metabolic, drug, and organic causes

  • Thiamine, B12, thyroid, uremia, hepatic encephalopathy, lupus, sarcoid, syphilis, recreational drugs, medication side effects, etc

Diagnosis of Increased ICP

  • Physical exam often inadequate as papilledema often does not show up immediately.
  • ONSD for Increased ICP – How To by the Ultrasound Podcast

  • If >5mm, suggests increased ICP and better than clinical exam [Tintinalli, 8e, p 1549]
  • Cushing’s Triad (bradycardia, agonal respirations, hypertension) – only present in <1/3 of cases of life-threatening increased ICP

Treatment of Increased ICP

  • Normalize the patient – normotensive, normocarbic (35-40 mmHg), normothermic
  • Adequately sedate the patient, raise head of bed to 30 degrees
  • Impending herniation?  These patients may need repeat CT.  Consider mannitol 0.25 – 1 gram/kg IV bolus, consider very brief hyperventilation, call neurosurgery
  • Rosenalli (Rosen’s + Tintinalli) both do not recommend hypertonic saline (3% NaCl) for the treatment of increased ICP

Generously donated Rosh Review questions (scroll for answers)

Question 1.

A young man is involved in a motor vehicle collision and sustains a severe head injury. In the ED, his GCS is 7. His blood pressure is 115/70 mm Hg and heart rate is 85 beats per minute. His pupils are 3 mm and equal and reactive to light. You intubate the patient and place him on a mechanical ventilator. The FAST ultrasound is negative and there are no other obvious injuries.

A. Avoid hypotension

B. Administer mannitol

C. Hyperventilation

D. Initiate induced hypothermia

Answer

B.  In patients with traumatic brain injury (TBI), hypotension has been shown to have a devastating effect on outcome. An early measurement of cerebral blood flow (CBF) in TBI patients demonstrates ischemic levels. This initial inadequacy of CBF may cause irreversible damage. Therefore, maintenance of adequate CBF by avoiding hypotension and maintaining a normal or even elevated blood pressure is one of the key principles in management of TBI. Mannitol (B) is an osmotic agent sometimes utilized in TBI patients when there is evidence of significantly elevated intracranial pressure and impending cerebral herniation.  Although this patient has an abnormal GCS, he does not exhibit signs of impending herniation.

Question 2.A 12-year-old boy presents to the emergency department with recurrent headaches. The headaches have been present for the past four weeks and are increasing in intensity. They are worse in the morning and when lying flat, and are associated with vomiting but no nausea. For the past few days, he has complained of blurry vision. His initial exam is notable for altered mental status, extensor posturing, and papilledema. Which of the following are the most likely vital sign abnormalities?

Answer

C. The most common clinically significant traumatic herniation syndrome is uncal herniation, a form of transtentorial herniation.  As the uncus is compressed, cranial nerve III is compressed. The first signs of compression include anisocoria, ptosis, impaired extraocular movements, and a sluggish pupillary light reflex ipsilateral to the expanding mass lesion. As the compression progresses, the ipsilateral pupil dilates and becomes nonreactive.

Good FOAM reviews:

 

PlayPlay