Headache
Dr Sarah RobinsonConsultant Emergency Medicine
Southampton
Headache
Life-threatening Causes:
• Subarachnoid haemorrhage• Meningitis/ encephalitis• Space Occupying Lesion • Temporal Arteritis • Pre-eclampsia
Headache
Other diagnoses to consider
• Venous sinus thrombosis• Dissection• Hypertensive encephalopathy• Glaucoma/ iritis• CO poisoning
Headache
Diagnoses you will not make in the ED
• Migraine• Coital cephalgia• Exertional headache
Headache
History
• Site• Onset• Character• Radiation• Associated symptoms• Timing• Exacerbating/ relieving• Severity
Headache
Red flags: history
• Thunder-clap headache• Worse headache ever
• Syncopal episode• Altered mental state• Onset with exercise• Worse on waking• Seizure
Headache
Beware...
• Elderly• Immunocompromised• Previous neurosurgery (shunts)
Headache
Red flags: signs
• Fever• Altered mentation• Focal neurology• Meningism
Headache
Examination
• Appearance• Photophobic
• Rash• Temperature• BP
• Kernigs/ Brudzinski• Focal neuro deficit• Visual fields• Fundoscopy
Headache
Subarachnoid haemorrhage
• Up to 50% initially misdiagnosed– 15% re-bleed early– 40% re-bleed in next 4/52
• 1 in 10 ED Pts with thunderclap headache
Headache
SAH: aetiology
• Family history• Smoking• Hypertension• Alcohol• Cocaine
Headache
SAH: history
• Most thunderclap• Worse headache ever
• Seizure at onset
• Neck stiffness
Headache
SAH: signs
• May be normal
• Decreased GCS• III CN palsy• Retinal haemorrhages
Headache
Headache
SAH: investigations
• CT– 98% sensitive if within
12 hours
• LP
Headache
SAH: Management in ED
• ABCD defG• Analgesia• Anti-emetic
• D/W senior
• CT and refer
Headache
SAH: pitfalls
• “not worse ever headache”
• “Headache improved with cocodamol”
• “CT was negative”
Headache
Meningitis
• Headache• Fever• Neck stiffness• Altered mental state
• Sepsis/ SIRS
Headache
Temporal arteritis
• Older• Scalp tenderness• Jaw claudication
• ESR
Headache
Summary
• Thunderclap headache?
• Senior review
• Never diagnose migraine in ED
Headache
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