[Music]
hi we're gonna be talking about the
approach to headache in the emergency
department thinking about patients who
present with headaches to the emergency
department it's important to think about
how often you're gonna see this
so headache is a really common
presenting complaint to the emergency
department there's about five million
visits estimated per year in the United
States and the other thing is that this
can be part of constitutional symptoms
so if you can think back to the last
time that you had a fever or had the flu
you probably had a headache with that
and that's part of a grouping of other
symptoms when patients present to the
emergency department with headaches we
think about dividing headaches into two
different groups so the first part is
primary headache disorders we're talking
about migraine headaches cluster
headaches tension headaches and this is
the majority of people that will come in
with headaches to the IDI secondary
headache disorders are due to organic
syndromes so that's due to patients who
have subarachnoid hemorrhages patients
who have meningitis that is a large
group of patients who present with
headaches but primarily here we're going
to be talking about these primary
headache disorders when patients come to
the emergency department with headaches
the history the ER gonna get from the
patient is very important and it's
important to try and get all the
elements of history from your patient
that you're able to first we're going to
talk about the onset of symptoms you
know this is very important especially
when we're trying to think about whether
or not the patient has an organic cause
primarily a subarachnoid hemorrhage
thinking about headache headache is
something that we think about because in
the differential of consequence so when
we're thinking about the most dangerous
things that can cause headaches we're
thinking about the meningitis we're
thinking about patients with a
subarachnoid hemorrhage in their brain
and our goal here is to rule out those
things because like I said the most
primary reason that people come to the
emergency department is for migraine
headache or cluster headache and those
patients just need symptomatic treatment
our goal here is to try and find the few
patients that have that organic cause
for headache so thinking about the aunt
did the headaches start suddenly or was
it a gradual onset so did the headaches
start over a period of seconds or
minutes or did it start over a period of
hours
was it a thunderclap headache what that
basically means is the headache started
all of a sudden like a thunderclap so it
started very very very suddenly in
nature so all of a sudden they didn't
have a headache and then one second
later they had a very very severe
headache what were they doing when their
headaches started and we'll talk about
some of the common things that point you
in the direction of the headache being
more related to a serious cause so are
they just sitting around
or were they exerting themselves what
are the associated symptoms are there
any neurologic changes is the patient
having any weakness any sensory deficits
are they having difficulty walking
are they having difficulty with their
speech or their vision trying to get
that information from the patient is
very very important are they having a
fever if they have a fever associated
with their headache that may point you
in the direction of meningitis or an
infection around the brain are they
having any vomiting vomiting can be both
a concerning symptom but can also be a
common thing that patients who have
migraine headaches present with so
vomiting and migraine headache do
sometimes go hand-in-hand
was there any loss of consciousness
patients who present with a headache and
loss of consciousness definitely can
point you in the direction of the
subarachnoid hemorrhage is there any
signs of meningitis do they have a stiff
neck are they able to move their neck
adequately and was there any trauma was
there any history of blow to the head
any kind of accident prior headache
history is also very very important does
the patient have a history of similar
headaches is this their worst ever
headache sometimes patients can say this
is the most severe headache I've ever
had it's very important to think about
how you phrase that question to a
patient so if you phrase that question
to the patient by saying is this your
most severe headache you've ever had
they might definitely say yes but
sometimes it's helpful to say can you
compare this headache to other headaches
that you've had is it of similar quality
is it the more severe it did it is it
just lasting longer
what are the things that made you come
to the emergency department for this
headache especially in patients who have
a known history of headache disorder and
then thinking about what they were doing
when the headache started did the
headaches start with exertion did it
start when they were having sexual
intercourse or a valsalva maneuver those
three things so headaches that start
with exertion sexual intercourse or
valsalva all can point you in the
direction again of subarachnoid
hemorrhage so by taking these history
and getting these historical points
we're basically trying to help
distinguish who has nan concerning
headache or a benign headache from the
patients that have that underlying
serious organic causes of headache
moving on to the physical exam our job
here again is to help distinguish those
concerning organic causes of headache
from a primary headache process things
that are very important to do on the
physical exam are to look at the back of
the eye and try and look for papilledema
or swelling in the back of the eye any
evidence of papilledema definitely
should prompt you to think about a more
concerning underlying cause of the
headache
there's lots of different things that
can cause papilledema but definitely any
kind of mass in the brain is one of them
our elevated intracranial hypertension
is another common cause of patients
presenting with headache to the
emergency department a neurologic exam
is a very important thing that you want
to make sure you do for your patients
you want to make sure that you check
their cranial nerves you examine them
and make sure that those are all normal
you want to check their strength as well
as their sensation as well as
potentially having your patients stand
up and checking their gait and walking
them around the room or the emergency
department to make sure that they have a
steady gait along with that cerebellar
maneuvers can help you determine whether
or not your patient has any concerning
findings in the cerebellar exam
assessing your patient for meningismus
is another important thing to do on the
physical exam what that basically means
is you want to have your patient flex
their neck
patients who have meningitis will have a
lot of difficulty or pain when they're
going to flex their neck there's other
maneuvers that you can do the Kearney's
and birds in ski maneuvers
and those will be discussed in another
lecture but those can also indicate
inflammation in the meninges so how do
we think about the diagnosis here we
want to basically think about how
concerned we are for a secondary
headache etiology primary headaches
generally don't require additional work
ups so for example if a patient comes in
and they say they have a migraine
headache that feels very similar to
their other migraine headaches you
generally don't need to do additional
testing or workup you know if you're
worried that someone has one of these
secondary headache ideologies those are
the patients so you want to start
thinking about doing additional testing
so what do we think about doing when
patients have headaches you want to
think about doing a non-contrast head CT
that's our initial testing that we do
for patients who present with headaches
and the non-contrast head CT is great at
looking for any kind of acute blood in
the brain so looking for a subarachnoid
hemorrhage as our cat scan machines get
better and better we're better able to
see subarachnoid blood and that also
whether or not you're able to see it on
a non-contrast head CT will depend on
the timeframe with which the patient
presents to the emergency department we
know that the non-contrast head CT is
most sensitive in the first 6 hours
after the headache began for
subarachnoid hemorrhage we also want to
think about doing a CTA which is a CT
angiogram or a CT venogram of the head
those get a better look at the blood
vessels both the arteries as well as the
veins that supply blood to the brain and
can help give a better idea as to
whether or not there's a bleed or an
aneurysm present then you want to think
about doing any labs labs can sometimes
point you in a direction of concern for
infection or a possible other underlying
reason for altered mental status and for
a patient in whom you're worried about
meningitis they may need a lumbar
puncture with analysis of their
cerebrospinal fluid and that will be
talk more about in another lecture
[Music]
you