Headaches in ED
- The key to proper management is to make an accurate diagnosis.
- Recognize the features of “dangerous” headaches, and know how to “rule out”.
IHS Diagnostic Classification
- Primary Headache: 90%
- Secondary Headaches: 10%
- Headache Characteristics:
- Temporal profile: acute vs chronic, frequency
- Location and radiation
- Alleviating and exacerbating factors
- Associated symptoms
- Constitutional symptoms
- PMH: HTN, DM, hyperlipidemia, smoking
- Blood pressure
- Auscultation for bruits in H/N
- Temporal artery inspection and palpation
- Neurologic exam: motor, sensory, coordination and gait
Acute onset headache
- Sufficient evidence from retrospective and prospective studies to support the association of an acute sudden onset headache with a vascular event.
- Sudden onset headache is a red flag
Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39.
Life Threatening causes of acute headaches:
- Subdural hemorrhage
- Subarachnoid hemorrhage.
- Hypertensive encephalopathy.
- 80% of non traumatic hemorrhages from ruptured saccular aneurysms.
- Other causes: AV malformations, neoplasms, blood dyscrasias.
- Commonest ages 40-60 yrs.
- Estimated that 5% of population have a berry aneurysm.
- Smoking and alcohol
- Sympathomimetic drugs
- Polycystic kidney disease
- Coarctation of the aorta
- Marfans syndrome.
useful signs and symptoms
- Sudden onset of worst headache of life.
- Worse on exertion eg valsalva, exercise.
- 75% of patients have nausea and vomiting.
- 50% of patients have meningism.
- 25% of patients have neck stiffness.
Linn F et al: Prospective study of sentinel headache in aneurysmal subarachnoid hemorrhage, Lancet 344:590, 1994.
Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage, J Neurosurg 25:219, 1966.
- Dull, mild generalized head pain.
- Symptoms of chronic SDH may be subtle.
- Up to 50% have altered level of consciousness
- Headache is worse at night and same side as hematoma
- On exam patient may have unilateral weakness and increased reflexes.
useful signs and symptoms.
- The absence of fever, neck stiffness and altered mental status in a patient with a headache virtually eliminates the diagnosis of meningitis.
- In multiple studies the presence of neck stiffness on examination has a pooled sensitivity of 70%.
- Does this adult patient have meningitis? Attia et al. JAMA 1999;281(2):175-181
Signs of Meningism.
- In a prospective study of young adult patients Kernigs sign had a sensitivity of 9% and a specificity of 100%.
- Brudzinskis sign has not been evaluated since the original report .
Uchihara T, Tsukagoshi H. Headache 1991;31:167-171.
Dr. Tariq Syed
Consultant in EM
University Hospital Birmingham