The Acute HeadacheThe Acute Headache

Devorah Nazarian, M.D.

Mount Sinai School of Medicine

April 12, 2002

Patient PresentationPatient 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

Patient Presentation continuedPatient Presentation continued

• P.E.-Vitals Temp 97.4 BP 122/74 HR 90 RR 16 General: appears in discomfort with eyes shut Neuro: A&Ox3, 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

IntroductionIntroduction

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

serious underlying problem.

Question # 1Question # 1

Does a Response To Therapy Predict The

Etiology of an Headache?

Causes of a HeadacheCauses 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

Common Pathway for Pain Regardless of Common Pathway for Pain Regardless of Underlying Etiology of the HeadacheUnderlying 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

So What Does the Evidence Show?So What Does the Evidence Show?

Response of Headaches in Nonnarcotic Response of Headaches in Nonnarcotic Analgesics Resulting in Missed Intracranial Analgesics Resulting in Missed Intracranial

HemorrhageHemorrhage• 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 . 1995;13:43-45

Dihydroergotamine and Metoclopramide Dihydroergotamine and Metoclopramide in the Treatment of Organic Headachein 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. 1995;35:637-638

Sumatriptan Relieves Migraine-like Sumatriptan Relieves Migraine-like Headaches Associated with CO Headaches Associated with CO

ExposureExposure

• 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. 1997;37:392-395.

Patient Management Patient Management RecommendationRecommendation

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

Question # 2Question # 2

Which Patients With Headache Require Neuroimaging

in the ED?

What Is the Goal of What Is the Goal of Neuroimaging in the ED?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

So What Does the Evidence Show?So What Does the Evidence Show?

Patients With Headache and Patients With Headache and Abnormal Neurologic Exam Require Abnormal Neurologic Exam Require

NeuroimagingNeuroimaging • 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

Predictors of Intracranial Pathologic Predictors of Intracranial Pathologic Findings in Patients Who Seek Findings in Patients Who Seek

Emergency Care Because of HeadacheEmergency 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. 1997;54:1506-1509

Practical Selection Criteria for Practical Selection Criteria for Unenhanced Cranial CT in Patients With Unenhanced Cranial CT in Patients With

Acute HeadacheAcute 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. 1994;94:67-70

Acute Headache of Recent Onset Acute Headache of Recent Onset and Subarachnoid Hemmorrhageand 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. 1994;34:172-174

Further Support for Neuroimaging Further Support for Neuroimaging with Severe Headachewith 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. 1989;9:87-90 MillsML, Russo Ls, Vines FS, Et al . High yield criteria for urgent cranial CT scans. Ann Emerg Med. 1986;15:1167-1172

Headache in HIV Related DisordersHeadache 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. 1991;31:518-522

A Decision Guideline For ED Utilization A Decision Guideline For ED Utilization of Noncontrast Head CT in HIV Infected of Noncontrast Head CT in HIV Infected

PatientsPatients• 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. 1999;6:1010-1019

Patient Management Patient Management RecommendationsRecommendations

• 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.

Question # 3Question # 3

Is There a Need for Emergent Angiograghy in the Patient

with a “Thunderclap Headache” Who Has Negative Findings In Both CT and LP?

Thunderclap HeadachesThunderclap 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 1986;2:68-70

So What Does the Evidence Show?So What Does the Evidence Show?

Long-Term Follow-up of 71 PatientsLong-Term Follow-up of 71 PatientsWith TCHA Mimicking SAHWith 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.1988,2:68-70

Vasospasm as a cause of TCHAVasospasm 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.1995;35,:1-6Dodick DW, Brown RD, Britton JW, et al. Nonaneurysmal thunderclap headache with diffuse, multifocal, segmental, and reversible vasospasm. Cephalagia. 1999; 19:118-123

TCHA Is It a Migraine? 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. 1989;9:87-90

The Clinical Spectrum of Unruptured The Clinical Spectrum of Unruptured Intracranial AneurysmsIntracranial 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. 1993;50:265-268

Identification and Treatment of Identification and Treatment of Cerebral Aneurysms after Sentinel Cerebral Aneurysms after Sentinel

HeadacheHeadache• 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. 1992;42:1118-1119

Other Entities Which Can Cause a Other Entities Which Can Cause a TCHATCHA

• cerebral venous thrombosis can present TCHA without neurologic findings

• vertebral artery dissection and internal carotid artery dissection often are associated a sudden severe headache

Patient Management Patient Management RecommendationsRecommendations

• 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 .