Acute Headache in the Emergency Department

Acute Headache in the Emergency Department

By Courtney Cassella, MD
Resident Physician, Icahn School of Medicine at Mount Sinai

Edited by Stephen Alerhand, MD and Alex Koyfman, MD

Clinical Case

A 56-year-old woman with a past medical history of hypertension and diabetes mellitus presents with a gradual onset, severe headache for the past 8 hours. The headache is described as the worst headache of her life, sharp, starts anteriorly and radiates to the back of the head/neck. The patient is nauseous but has not vomited. She denies fevers, chills, neck stiffness, vision changes, eye pain, numbness, or weakness.

Physical examination reveals an afebrile, mildly hypertensive, alert and oriented woman in severe distress secondary to pain. Otherwise, physical examination is unremarkable with no neurologic deficits.

Differential Diagnosis

Emergent

• Subarachnoid or Intracerebral Hemorrhage
• CNS infection: Meningitis, Encephalitis, Brain abscess
• Carbon Monoxide Poisoning
• Temporal Arteritis
• Increased Intracranial Pressure: Mass, Idiopathic Intracranial Hypertension, Shunt Failure
• Cerebral Sinus Thrombosis
• Cervicocranial Artery Dissection
• Subdural Hematoma
• Acute Angle Closure Glaucoma

Non-emergent

• Tension
• Migraine
• Cluster
• Febrile headache
• Dental, TMJ
• Trigeminal Neuralgia
• Post-Lumbar Puncture headache

General Approach to Evaluation _{3, 6, 22, 23}

History of Present Illness

Onset
— Sudden versus gradual onset
— Rest versus exertion (including cough, bowel movement, sexual activity)

Location
— Although this is not reliable for diagnosis, in a constellation of symptoms can point toward a specific type of headache.

Aggravators/Alleviators
— Worse with awakening/bending over (increased intracranial pressure)
— Comes and goes with specific enclosed settings (carbon monoxide)
— Others with similar headache in the household or place of work (carbon monoxide)

Associated symptoms
— Nausea, vomiting, photophobia (non-specific)
— Altered mental status, confusion
— Syncope
— Seizure
— Vision changes, eye pain (glaucoma)
— Jaw claudication (temporal arteritis)
— Numbness, weakness

Other History Points
— Prior headaches
— Prior neuroimaging
— Immunosuppression, Hypertension, Diabetes Mellitus, Malignancy, Coagulopathy
— Pregnant, postpartum
— Medications including nitroglycerin, analgesics, MAOIs, anticoagulants, birth control
— Alcohol, cigarette, or cocaine use

 Family history
— Relatives with subarachnoid hemorrhage
— Migraine headaches

Physical exam

General
— Mental status, orientation

Vital Signs
— Hypertension
— Bradycardia
— Fever

HEENT
— Palpate temporal artery
— Palpate TMJ, mouth opening/closing
— Kernig or Brudzinski signs (not sensitive)
— Conjunctival injection, pupil reactivity, visual acuity, slit lamp exam, fundus examination for papilledema

Neurologic
— Cranial nerve examination – CN VI palsy (increased ICP)
— Strength, Sensation, Reflexes
— Finger to nose, Heel to shin, Rapid alternating movements, Pronator drift, Romberg
— Gait – ataxia

Clinical Features of Dangerous Headaches _{3, 6, 24}

Subarachnoid or Intracerebral Hemorrhage _{2, 10}

HA Quality: “Thunderclap headache”: sudden, severe, reaches maximal intensity within minutes, onset with exertion

Associated sx: nausea, vomiting, nuchal rigidity, altered mental status, syncope, seizure

Hx: recent severe headache (sentinel bleed), family history of SAH, hypertension, smoking, cocaine use, connective tissue disease (SAH), amyloid angiopathy (intracerebral)

Exam: change in mental status, neurologic deficits commonly cranial nerves, motor

CNS Infection _14-16

HA Quality: gradual, moderate to severe

Associated sx: fever, meningismus, altered mental status, seizures, rash, photophobia, psychiatric sx (encephalitis), cognitive deficits (encephalitis)

Hx: immunization status, recent outbreaks, local epidemics, sinusitis, otitis media, brain surgery, military barracks, dormatory

immunocompromised (HIV, AIDS, immunosuppressants) à think cryptococcal meningitis, toxoplasmosis

Exam: altered mental status, Kernig, Brudzinski, papilledema, skin exam, focal neurologic deficits

Carbon Monoxide Poisoning _{8, 9, 17}

HA Quality: gradual, intensity does not correlate with COhb levels, dull or throbbing, frontotemporal or diffuse, no pattern rules out or in carbon monoxide₁₀

Associated sx: dizziness, fatigue, weakness, nausea, vomiting, confusion, syncope, seizure, chest pain (rare), dyspnea (rare)

Hx: headache in the winter months, household or work contacts with headache, evidence of self harm, ask about suicidal intent

Exam: confused to comatose, ataxia (severe)

Temporal Arteritis _{21, 25}

HA Quality: gradual, severe, throbbing, unilateral frontotemporal

Associated sx: jaw claudication, vision changes/loss of vision, polymyalgia rheumatic, scalp tenderness

Hx: new onset or change in pattern of HA, HA with brushing hair, jaw pain after latency of tough chewing localized at the muscles

Exam: temporal artery tenderness, absent temporal artery pulsation, change in visual acuity

Criteria (3 of 5) ₁₂

• >50y
• New-onset localized headache
• Temporal artery tenderness or decreased pulse
• ESR >50mm/H
• Abnormal arterial biopsy findings

Increased ICP: tumor/mass, idiopathic intracranial hypertension (IIH), shunt failure _{7, 13, 24}

HA Quality: gradual, unilateral or bilateral

“Classic”: severe, early morning or nocturnal

Typical: moderate to severe, intermittent, nonspecific (aching, pressure, tightness, throbbing, shooting), progressive

IIH: lateralized, throbbing

Associated sx: nausea, vomiting, vision changes, neurologic deficits

Hx: HIV/AIDS à CNS lymphoma; malignancy à brain metastasis; history of shunt

IIH: young, female, obese

Exam: papilledema, neurologic deficits, CN VI palsy, skull-based metastases syndromes described by Greenberg et al₇

Cerebral Venous Thrombosis _{20, 27}

HA Quality: 1/3 acute, 1/3 sub-acute (<1mo), 1/3 chronic, diffuse

Associated sx: nausea, vomiting, seizures

Hx:

• Hypercoagulable states: Oral contraceptive use, postpartum, post-operative, malignancy
• Coagulation disorders: Factor V Leiden, Antithrombin III deficiency, Protein C or S deficiency, plasminogen deficiency, hyperhomocysteinemia
• Polycythemia, sickle cell disease
• Vasculitis – Behcet’s ,Wegener’s granulomatosis, sarcoidosis
• Septic CVT – local (i.e. mastoiditis, otitis media, sinusitis, tonsillitis) or generalized (i.e. septicemia, endocarditis)

Exam: +/- papilledema, fluctuating neurologic deficits

• Cavernous sinus – ocular nerve palsies, ipsilateral ocular affection (chemosis, proptosis, papilledema)
• Lateral sinus – aphasia if left
• Deep cerebral venous system – coma, motor deficits, aphasia

Cervicocranial Artery Dissection ₁₈

HA Quality: sudden or gradual, severe, non-throbbing, occipital (vertebral), facial/frontotemporal pain (internal carotid)

Associated sx: nausea, vomiting, neck pain, vertigo

Hx: minor trauma within 6 hours of onset of head/neck pain

Exam:

Internal Carotid

• Audible pulsatile tinnitus for the patient or bruit
• Partial Horner syndrome – ptosis, meiosis without anhidrosis
• Cranial nerve palsies, particularly lower (III – diplopia, V – facial numbness, VII – facial paresis, XII – tongue deviation)

Vertebral

• Resemble lateral medullary syndrome

Upper extremity weakness

Subdural Hematoma ₃

HA Quality: gradual, moderate to severe

Associated sx: nausea, vomiting, altered mental status

Hx: elderly, remote trauma, history of alcohol abuse, anticoagulation

Exam: change in mental status, neurologic deficits

Acute Angle Closure Glaucoma _{1, 26}

HA Quality: sudden, moderate to severe, centered about the eye

Associated sx: nausea, vomiting, blurred vision, foggy vision or halos

Hx: precipitated dilation, far sighted

Exam: mid-dilated, globe is hard, unreactive to light, reduced visual acuity, hyperemia more prominent adjacent to limbus, hazy cornea, tonometry >20mmHg

Neuroimaging Considerations

An assessment of the dangerous diagnoses of headache would be incomplete without mention of the ACEP Clinical Policy statement from 2008₅. This policy provides valuable recommendations for the evaluation of headache. Importantly, the level B recommendation for emergent neuroimaging includes:

• New abnormal finding on neurologic examination (altered mental status, altered cognitive function, focal deficit) (non-contrast head CT)
• New sudden-onset severe headache (head CT)
• HIV-positive patients with new type of headache (neuroimaging)

There is a level C recommendation for urgent neuroimaging, meaning outpatient neuroimaging should be arranged by the emergency physician, in patients older than 50 years of age with a new type of headache.

Although there are many sub-populations to be cognizant of when presented with the chief complaint of headache (elderly, pregnant women/postpartum, coagulopathic patients, those with subacute/subtle trauma, cancer patients), the immunosuppressed and particularly HIV-positive patients require special consideration. Given the high prevalence of HIV-positive patients with central nervous system complications, approximately 70%, the emergency physician should order a non-contrast head CT in HIV-positive patients presenting with₁₉:

• New seizure
• Depressed or altered orientation
• Headache different in quality
• Prolonged headache >3 days
• Focal neurologic deficit

Case Conclusion

As the patient was experiencing the worst headache of her life she was sent for a non-contrast head CT. The CT was concerning for fungal sinusitis. The patient was given broad spectrum antibiotics and antifungal coverage. She underwent lumbar puncture to evaluate for a fungal CNS infection and was admitted.

References and Further Reading

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3. Dentali F, et al. “D-dimer testing in the diagnosis of cerebral vein thrombosis: a systemic review and a meta-analysis of the literature.” J Thromb Haemost 2012; 10(4): 582-9.
4. Edlow JA, et al. “Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.” Ann Emerg Med 2008; 52(4): 407-36.
5. Godwin SA, Villa J. “Acute headache in the ED: Evidence-Based Evaluation and Treatment Options.” Emerg Med Pract 2001; 3(6): 1-32.
6. Greenberg HS, et al. “Metastasis to the base of the skull: clinical findings in 43 patients.” Neurology 1981; 31(5): 530-7.
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8. Hampson NB, et al. “Practice recommendations in the diagnosis, management, and prevention of carbon monoxide poisoning.” Am J Respir Crit Care Med 2012; 186(11): 1095-101.
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11. Hunder GG, et al. “The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis.” Arthritis Rheum 1990; 33(8): 1122-8.
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15. Moran GJ, House HR. “HIV-Related Illnesses: The Challenge of ED Management.” Emerg Med Pract 2002; 4(1): 1-28.
16. Nikkanen H, Skolnik A. “Diagnosis and management of carbon monoxide poisoning in the emergency department.” Emerg Med Pract 2011; 13(2): 1-14.
17. Rahme RJ, et al. “Spontaneous cervical and cerebral arterial dissections: diagnosis and management.” Neuroimaging Clin N Am 2013; 23(4): 661-71.
18. Rothman RE, et al. “A decision guideline for emergency department utilization of noncontrast head computed tomography in HIV-infected patients.” Acad Emerg Med 1999; 6(10): 1010-1019.
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22. Trevias B. “Headache.” Mini Intern Boot Camp Cardinal Symptoms Summaries http://www.emdocs.net/wp-content/uploads/2014/05/Headache-BTAK.pdf Accessed 1/4/15
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25. Walker RA, Srikar Adhikari. “Ch. 236 Eye Emergencies.” Tintinalli 7^th Pg. 1517-1118-1549
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