Let’s now take a look at
acute severe headache.
What caused the intracerebral hemorrhage
resulting in such a secondary headache?
meningitis, temporal arteritis,
cluster headache, and
Remember, with an acute severe
headache, with a hypertensive urgency
versus something known as your
let’s say when we talked
we had crisis and
we had urgency.
We talked about the
differences between the two.
Under acute headache, here once
again, subarachnoid hemorrhage.
We know about the thunderclap.
We’ve talked about this being the
worst headache in the patient’s life.
Severe, nausea, and vomiting,
altered level of consciousness,
and may present in coma
worst case scenario.
We talked about the Hunt and Hess scale.
And may have a focal neurologic
deficit and signs of meningismus.
Remember, we talked about if there was
a berry aneurysm which was large enough
and it ruptured, may result in
a subarachnoid hemorrhage.
If left untreated, may also
result in a, perhaps, herniation.
acute in onset.
Focal deficit commonly
Altered level of consciousness related
to location and size of the bleed.
And small bleed in pons can
significantly depress consciousness.
Do not confuse this with
This is hemorrhage taking place
of the brain structure itself.
Larger cerebral bleed can cause edema,
mass effect, and perhaps even herniation.
With meningitis, we talked
about this in great detail.
Let’s talk about the headaches
that are associated.
In bacterial meningitis where we
have glucose being decreased,
neutrophils being elevated,
protein being elevated.
Here, we have headache
which is usually diffuse.
Fever and meningismus
May be absent in elderly
Look for that, please. Be careful.
Fever may not be necessarily seen.
Alteration in level of
consciousness is frequent.
I want you to compare this
with viral meningitis.
We have viral meningitis,
and we have protein content,
which is not so elevated.
If it's the WBC, then we’re
looking at lymphocytes;
and glucose tends to be normal.
A diffuse headache usually has
developed over several days.
Associated symptoms of fatigue
and myalgia are common.
Remember, when you
have viral infection,
then it’s not just
restricted to the meninges.
It could also very much
affect the muscle.
And we had that discussion earlier
when we talked about HIV and AIDS.
Level of consciousness and
neurologic exam should be
normal for the most part
with viral meningitis,
so you don’t have this alteration
on level of consciousness,
as you’ve seen with bacterial.
It’s an important table for you to compare
and contrast the type of headache
with bacterial and
With acute headache, temporal arteritis,
your patient most likely, an elderly
female, also known as giant cell arteritis.
Headache is typically intermittent,
unilateral, temporal area at first,
and then bilateral temporal
when it becomes continuous.
Pain is often
throbbing in nature.
“Doc, this headache that
I have is throbbing.”
“Where is it located?"
You should be thinking
definitely, temporal arteritis.
Aching and burning.
Tenderness of the scalp.
With temporal arteritis, remember,
this is a vasculitis of
medium to large vessel
diseases or blood vessels.
And if left untreated, meaning to
say that you do a biopsy, remember,
and you’re looking for granulomatous
type of lesion in your temporal artery
of approximately 2
to 3 centimeters.
And if left untreated, ophthalmic
branch of the temporal artery
might get affected and the patient
is then left with being blind.
Usually affects people over the
age of 60, women more than men.
Look for these being most
common type of presentations.
Remember, temporal artery
could have a branch.
We have jaw claudication, weight loss, low-
grade fever, fatigue, and amaurosis fugax.
In other words, your retina for sure is
going to get affected if left untreated.
Temporal arteritis associated findings:
firm and tender superficial
Obviously, ESR is non-specific.
We find this to be significantly
elevated with this type of history.
High on the differential should
be giant cell arteritis.
First is negative.
You need to make sure that you do
biopsy in the contralateral side
because as I told you,
the headache, throbbing on one side
but could be both if it’s continuous.
And just because you find it
to be negative on one side,
you need to make sure
that you rule this out.
Otherwise, as I said, your elderly
patient is at risk for blindness.
Angiography of external
until biopsy is negative.
Don’t take chances.
Steroids have continued for months
to years to prevent recurrence.
if that vision has been compromised,
very rarely does it recover.
Signs and symptoms:
headache, acute vision loss,
do not forget about jaw claudication,
decreased temporal pulsations.
Your superficial temporal
artery feels tender.
Differential diagnoses from
this type of headaches:
glaucoma, migraine, uveitis,
retinal artery occlusion,
We talked about significant elevated
levels of ESR, and biopsy is confirmatory.
And management for sure until that
biopsy comes back being negative.
Empirically, you need to
make sure the steroids
have been started