Headache (Emergency Medicine) – Emergency Medicine | Lecturio

[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


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