Overview Headache Emergencies Primary versus Secondary headache disorder Red flags 4 cases of unusual headache emergencies Disclaimer: we will not talk about brain bleed as patients usually go the ED. Juliette Preston, M.D. OHSU Headache Center INTRODUCTION Distinguish primary from a secondary headache disorders If atypical features exist or red flags, consider further investigations PRIMARY HEADACHE DISORDER The majority of headaches ( 90%) fall under 3 categories: Tension-type headache Migraine headache Cluster headache Is there an easy way to differentiate between them? Mild headache, not aggravated by movement tension-type headache Moderate to severe headache, pt wants to be still migraine headache Severe headache, pt cannot be still cluster headache. Other way to differentiate between them? Tension-type headache: > 30 min Migraine headache: > 4 hours Cluster headache: 15 min- 3 hours 1
Secondary headaches red flags (SNOOP₄) Systemic disease or symptoms (malignancy, fever, weight loss) Neurological signs/symptoms Onset that is sudden ( acute or thunderclap) Onset after 50 Previous HA history but now with new or different features Progressive Postural Precipitation by Valsalva or exertion Case 1 73 yo M with a pmh significant for DM-2, traumatic subdural hematoma s/p evacuation ( 6 yo ago), R posterior circulation stroke ( 2 yo ago) who presented with 6 month history of exertional headache. Shankar et al, Internal Medicine Journal 2016 Case 1 His headaches are generalized, dull in nature. They are triggered by moderate exertion ( mowing the lawn) and on exposure to cold air. Headaches resolved quickly in response to rest, within 5 minutes. They are not triggered by cough or straining. Case 1 Exam: 115/65 72 Neuro: intact Current meds: ASA, Enalipril and Simvastatin CTH ordered by internist was normal More history He presents with more frequent headache, which are now triggered by lower level of activity such walking around the house. Summary Older patient h/o DM, stroke Exertional headache Triggered by any activity Resolved with rest 2
CASE 1 Resting EKG: normal Treadmill stress test CASE 1 Had to be terminated at 5 minutes as he developed headache s and progressive ST depression in the inferior-lateral leads. 3 mm ST depression resolved with rest and headache relief Cardiac Cephalgia Headaches associated with either exertion-related ischemia or acute MI Resolves with medical or surgical treatment When chest pain symptoms are absent ( 20-30%), diagnosis is delayed Unlike migraine, it respond to Nitroglycerin It is associated with 3 vessels coronary artery disease Physiology Referred pain form the myocardium carried by autonomic afferent nerve fiber to the brainstem converging on other sympathetic or somatic sensory fiber supplying the head. Clues for diagnosis Age of patient Cardiac risk factors Close relationship between headache and exercise CASE 1 Angiogram: proximal 3 vessels diseases, ventricular systolic function was normal 6 months later, her had acute ST elevation MI, he underwent coronary artery bypass graft surgery. Headache free since then. 3
Clinical pearl Headache with exertion think of the heart. 73 yo man with a pmh significant for HTN, HL, OSA on CPAP, non-hodgkin s lymphoma ( s/p completed chemo 6 weeks prior) who presented 1 month of headache unresponsive to OTC medication. No prior history of headache Case 2 Headaches are located on the left side, temporal region Worse with lying down Associated with scalp sensitivity Partial vision loss in left eye 1 week prior ( OD 20/25, OS 20/40, IOP 17/16) What would you do next? Lab results: ESR 61 Hemoglobin 12.3 WBC 6.2 Platelets 252 CRP 4.6 Next step? Bilateral temporal artery biopsies was done. Found negative 1mg/kg of prednisone was given Complete vision loss one month later. 4
Clinical pearl There are other causes other than giant cell arthritis for new onset headache in the elderly with elevated ESR. GCA still remain an important one not to miss ( usually ESR >100). Secondary headaches red flags (SNOOP₄) Systemic disease or symptoms (malignancy, fever, weight loss) Neurological signs/symptoms Onset that is sudden ( acute or thunderclap) Onset after 50 Previous HA history but now with new or different features Progressive Postural Precipitation by Valsalva or exertion Clinical Pearl Sphenoid sinusitis is a medical emergency Consider in: elderly immunocompromised patients Patient with headache worsening with Valsalva or in supine position A 68 year old woman presented to the emergency department with a 10 day history of gradual onset left temporal headache and scalp tenderness, which had increased in severity over this period. She had a 40 year history of migraine, for which she had been prescribed Sumatriptan. She described her presenting headache as different from her usual migraine. She was otherwise well with no recent illness or head injury. 5
On examination she was normotensive and her temperature was also normal. There was no meningeal signs Her temporal arteries were non-tender on palpation. She had no neurological deficit and no papilledema on funduscopic exam. Her left temporomandibular joint was tender.» What do you do next? ESR: 2 mm CT brain : normal LP : opening pressure: 16.5 cm H2O CSF analysis was normal. What do you think? The risk of secondary headache increases with age. Causes of unilateral headache: Hemorrhage ( SAH/stroke) Temporal arteritis Trigeminal neuralgia Arterial dissection Cancer The next morning, she noted swelling of the tongue and difficulty in eating. She was able to swallow but found it difficult to move her tongue. She had no hoarseness. On examination her speech was dysarthric, and she had swelling over the left side of her tongue, with leftward deviation on tongue protrusion. Taste and tongue sensation were normal. Vascular imaging MRA showed reduction in caliber of L ICA (A) And pseudoaneurysm (B) i: pseudoaneurysm ii:ica vessel lumen iii: intramural hematoma What the next step? 6
PREVENT A STROKE BP and cholesterol control Antiplatelet versus anticoagulation? No evidence of superiority for anticoagulation Antithrombotic therapy is suggested for 3-6 months or until vascular defect in resolved. Endovascular stent angioplasty can be considered for patients who have recurrent ischemic symptoms despite maximal medical management, and for those with expanding pseudoaneurysms. Initially, she was started on steroid (temporal arteritis was suspected) and a referral for temporal artery biopsy was placed. After she developed tongue weakness, and carotid dissection was noted, she was started on ASA and steroids were stopped. Repeat imaging were done at 6 weeks, slight improvement in L ICA was shown. At 3 months in f/u clinic visit, her speech had improved with only occasional dysarthria. Clinical Pearl Dissection can present with headaches Don t skip the mouth exam, look at the tongue carefully. REVIEW Cardiac cephalgia- older, CAD risk factors Sphenoid sinusitis-unilateral HA, worse with supine position, CN palsies Internal carotid dissection-not always with neck pain, may present with HA/CN palsies Thank you 7