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