核心課程編號 :E1 急診部藍國徵主任 / 施長志醫師 104 年 12 月 15 日第四版

Transcription

1 核心課程編號 :E1 頭痛 急診部藍國徵主任 / 施長志醫師 104 年 12 月 15 日第四版

2 學習目標 知識 PGY

3 如何進行焦點式病史詢問及理學檢查 鑑別造成頭痛的原因, 找出有立即生 命危險的診斷?

4 Approach of headaches History: - onset - duration - frequency - character - severity - location - associated symptoms - prodromes - triggers - past headache/medical history - family history - medications - society history - menses (women)

5 Red Flags Headaches begin after age 50 Very sudden onset of Headache Change in frequency or severity Immunosupresion Fever, stiff neck, rash, trauma Focal neurologic symptoms or signs Papilledema

6 Approach of headaches Physical examinations: - Vital signs - Fundoscopy - Palpation of areas of head and neck - Auscultation of eyes, neck - Nuchal rigidity and meningeal signs - Complete neurological exam

7 When to consider neuroimaging Temporal profile and headache features: - The first or worst headache (thunderclap headache) - Subacute headache with increasing frequency or severity - Progressive or new daily persistent headache - Chronic daily headache - Side-locked - Headache not responding to treatment

8 When to consider neuroimaging Demographics: - New headache in patient with cancer or HIV - New headache age > 50 - Headache and seizures Associated symptoms and signs: - Fever, stiff neck, nausea and vomiting - Focal neurological symptoms or signs - Papilledema, cognitive impairment or personality change

9 熟悉各種原發性頭痛的分類與 造成次發性頭痛的急症

10 Causes of headaches Intracranial: - Migraine - Cluster headache - Brain tumor - Subarachnoid hemorrhage - Meningitis - Brain abscess - Temporal (giant cell) arteritis - Hypertension - Caffeine, alcohol, or drug withdrawal - Content adapted from CURRENT Medical Diagnosis & Treatment 2010.

11 Causes of headaches Intracranial: - Pseudotumor cerebri - Subdural hemorrhage - Cerebral ischemia - Arterial dissection (carotid or vertebral) - Arteriovenous malformation - Head injury - Lumbar puncture - Venous sinus thrombosis (intracranial venous thrombosis) - Postlumbar puncture - Carbon monoxide poisoning Content adapted from CURRENT Medical Diagnosis & Treatment 2010.

12 Causes of headaches Extracranial: - Systemic infections - Tension headache - Cervical arthritis - Glaucoma - Dental abscess - Sinusitis - Otitis media - Temporomandibular joint (TMJ) syndrome - Depression - Somatoform disorder (somatization) - Trigeminal neuralgia - Glossopharyngeal neuralgia

13 Common Causes of Headache

14 Headache Symptoms that Suggest a Serious Underlying Disorder

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16 Tension Headache Most common headache syndrome Episodic < 15 days per month Chronic > 15 days per month Precipitants include anxiety, depression and situational stress Characteristics: - 30 minutes to 7 days - Pressing or tightening (band-like) - Mild to moderate pain - Variable location, often bilateral - Nausea and vomiting rare

17 Migraine Moderate to severe pain Unilateral, pulsating 4 to 72 hours Nausea, vomiting, photophobia or phonophobia With or without aura Triggering factors -Stress - Menses - oral contraceptives - Infection - Trauma - Vasodilators - Wine

18 Simplified Diagnostic Criteria for Migraine

19 Differential Diagnosis of New Daily Persistent Headache

20 Cluster headache Episodic - Two episodes per year to one every two or more years 7 days to a year Chronic - Remission phases less than 14 days - Prolonged remission absent for > one year Affects men 6x>women. Onset in 3rd through 6th decades. Prevalence: 0.4 2%. Pain is severe, recurrent unilateral, orbital, supraorbital or temporal, accompanied by ipsilateral autonomic signs.

21 瞭解急性頭痛的藥物治療與急診 會診原則

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23 Preventive Management of Cluster Headache

24 能適當的安排並判讀神經影像學檢查 實驗室檢查與腰椎穿刺以輔助診斷

25 CT Noncontrast CT is the best neuroimaging test for diagnosing an acute subarachnoid hemorrhage Although negative findings on a CT scan alone cannot exclude subarachnoid hemorrhage

26 Lumbar Puncture Suspected meningitis or suspected subarachnoid hemorrhage when CT scan findings are normal. LP should be preceded by CT scan if raised intracranial pressure is suspected to determine if contraindications to LP exist. Absence of papilledema by itself is unreliable, because papilledema may not be apparent with rapidly developing intracranial pressure, or even with high levels of pressure.

27 MRI MRI is more sensitive than CT in evaluating brain injuries, such as diffuse axonal injuries, small parenchymal contusions, isodense subdural hemorrhages, and most tumors. In acute subarachnoid hemorrhage, however, and as of this writing, MRI is no more sensitive than CT in the first few days following a bleed. CT and LP are adequate for the large majority of ED headache patients requiring emergent investigation.

28 Temporal Arteritis Moderate to severe, unilateral pain Patients over 65 Tortuous scalp vessels ESR elevated Biopsy for definitive diagnosis Treat with steroids Untreated complicated by vision loss

29 Subdural Hematoma (SDH) History of trauma Fluctuating level of consciousness Pain lateralized Tenderness to percussion over hematoma Trauma may be remote in chronic SDH Besides trauma, risk factors include cerebral atrophy, bleeding diathesis, alcoholism, old age and dialysis

30 Subarachnoid Hemorrhage (SAH) Sudden onset, severe, generalized pain Etiology of SAH: - Ruptured aneurysm 85% - Non aneurysmal perimesencephalic bleed 10% - Other causes 5% Nausea and vomiting Stiff neck progressing to back pain Lumbar puncture if imaging negative (Noncontrast CT will dx 90% of SAH)

31 Post-Concussive Syndrome Headache, vertigo, and cognitive complaints Pathology is poorly understood and symptoms correlate poorly to severity of trauma Head CT may be necessary to exclude chronic subdural hematoma or hydrocephalus Treatment includes counseling, physical therapy, and medications used for tension-type headache.

32 Brain Tumor (1) In elderly, brain tumor is usually metastatic from lung or breast carcinoma. Primary brain tumor are more common in adults younger than 50 years Headache is caused either by direct pressure on the brain or elevated intracranial pressure. Typical presentation is headache that worsens over weeks to months

33 Brain Tumor (2) Headache is usually present on awakening initially, then it becomes continuous. Headache is often worse with sneezing, bending, coughing. Diagnostic tools include CT with IV contrast or MRI(best test)

34 Intracranial Infection Headache is common complaint in meningitis, brain abscess, encephalitis or AIDS Diagnostic tools include CT of head and lumbar puncture Meningitis Encephalitis Brain Abscess AIDS Severe headache, nuchal rigidity, meningismus headache, confusion, fever, change of mental status, seizures headache, vomiting, focal neurological signs, depressed level of consciousness Toxoplasmosis, CMV, Cryptococcus

35 Hypertensive Headache Elevated blood pressure is not as important in headache as the rate by which the blood pressure increases Nonetheless, headache with severe HTN is well documented especially in hypertensive encephalopathy Treatment is directed at lowering blood pressure slowly Headache may last for days until brain edema has resolved

36 Acute Glaucoma Sudden onset of eye pain radiating to head, ear, teeth, and sinuses. Visual symptoms include blurriness, halos around lights, and scotomas. Nausea and Vomiting Due to elevated intraocular pressure (IOP) Medications that elevate IOP: mydriatics, sympathomimetics Physical exam shows a red eye with a fixed middilated pupil and shallow anterior chamber Treatment includes topical miotics, b-blockers, carbonic anhydrase inhibitors, optho consult

37 Sinus Headache Acute/chronic sinusitis Constant, dull, aching Worsened with jarring, stooping or leaning forward Referred pain possible

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