We're gonna be talking about the approach to headache
in the Emergency Department.
Thinking about patients who present with headache
to the Emergency Department,
it’s important to think about how often you’re gonna see this.
So a 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,
And this is the majority of people
that will come in with headaches to the ED.
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 gonna be talking about these primary headache disorders.
When patients come to the Emergency Department with headaches,
the history that you’re 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 gonna talk about the onset of symptoms.
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 the 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 a migraine headache or a cluster headache,
and those patients just need symptomatic treatment.
Our goal here is to try and find a few patients
that have that organic cause for headache.
So thinking about the onset.
Did the headache start suddenly or was it a gradual onset?
So did the headache 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 headache 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 were 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 but more severe?”
“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 headache 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 a non-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,
or an 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 wanna make sure you do for your patients.
You wanna make sure that you check their cranial nerves,
that you examine them and make sure that those are all normal.
You wannna check their restraint 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,
cerebellum 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 wanna 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 Kernig's and Brudzinski 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 wanna 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 work up.
If you’re worried
that someone has one of these secondary headache etiologies,
those are the patients
who you wanna start thinking about additional testing.
So what do we think about doing when patients have headaches?
You wanna 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 then also,
whether or not you’re able to see it on a non-contrast head CT
will depend on the time frame
with which the patient presents to the Emergency Department.
We know that the non-contrast head CT
is most sensitive in the first six hours
after the headache began for a subarachnoid hemorrhage.
We also wanna 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 aneurism present.
Then you wanna 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 talked more about in another lecture.