Let’s talk about hypertensive urgency as
being a presentation of acute headache.
Dull, bilateral ache head pain,
no focal deficit,
level of consciousness
if associated with reversible posterior
type of leukoencephalopathy.
Usually seen when systolic
blood pressure is above 170
and the diastolic blood
pressure is above 110.
Treatment here is you need to make sure
that you take care of the hypertension.
Urgency versus your crisis, or emergency,
and your crisis is the one in
which you don’t mess around.
At that point, you need to
make sure that you give IV,
do everything in power in which
you give IV nitroprusside
to take care of the
blood pressure ASAP.
Remember, we talked about
hypertension urgency versus crisis.
Here, let’s talk about
a cluster headache.
The duration becomes important.
Abrupt in onset,
peaking approximately five
to ten minutes later.
That is important.
Pay attention to that.
Persists for 45 minutes to 2 hours.
And clusters, meaning to
say over days to weeks.
So it comes in these clusters,
over days to weeks.
Peak of five to ten, persists for 45
minutes to 2 hours, and comes in clusters.
and orbital in location.
“Doc, it feels like I have pain in my eye.
It feels like someone is
stabbing me in the eye.”
Pain described as deep, intense, boring,
meaning to say like a needle being put.
So, they don’t call
this being throbbing.
Throbbing will refer to as being
our giant cell arteritis.
“Doc, I feel like these pulsations
of throbbing headaches.”
Boring is more like a
needle, being stabbed.
These patients are moving around the
room, banging their head on the wall,
screaming for medication because could you
imagine putting a needle into your eye?
Isn’t a good feeling.
Nausea and vomiting are atypical,
associated with lacrimal
or nasal secretions.
Who does it occur in?
Young adult men.
Usually, onset will be 30s.
Male to female ratio, males much more
so than females with cluster headaches.
Now, suicide, an
This darn headache is so bad
that that patient is not able
to handle and manage this
by himself or herself,
most likely himself,
that he wishes to
then kill himself
due to the intense nature and
predictable recurrent rate of the pain.
That becomes important.
Even though we just
call this a headache,
we understand the implications
can quite literally be grave.
Let’s take a look at management
of cluster headache.
Abortive therapy is often
ineffective due to the rapid onset.
Remember, short duration of attacks.
So the peak is five
to ten minutes.
However, you say short duration.
Keep that in mind,
it’s all relative.
Forty-five minutes is actually not a lot
of time over a grand scheme of things.
However, for the patient,
it feels like eternity.
“Doc, my headache feels
like it’s forever.”
Yes, when you’re in that type of
pain, even 30 seconds is too long.
D.H.E sub-Q, narcotics,
face mask oxygen for
eight to ten liters,
intranasal lidocaine to
relieve some of this pain.
Prophylactically, lithium, perhaps.
Anti-epileptic here but
this is valproic acid,
and amitriptyline tends to be prophylactic
with the next set of cluster
headaches that might then recur.
In summary of cluster headache:
Risk factors: male, much
more so, young male, 30s.
Preventive medicine: lithium,
some of your calcium channel
blockers, amitriptyline, valproic.
Signs and symptoms: unilateral
boring, boring, boring.
By boring, you know what
I’m referring to now.
I’m not saying, “Well, I’m sitting on my
couch watching TV because I’m bored.”
No, no, no, this is boring
like you’re stabbing someone.
cerebral vein thrombosis.
Diagnostic workup: H&P,
image can rule out other diagnoses if
it’s causing this type of headache.
Treatment: we talked about
sumatriptan, narcotics, oxygen.