Scribd Logo
Upload

Welcome to Scribd!

  • 30 views

    Diagnoses and Management Acute Headache Emergency Department

    Uploaded by

    Bendy Dwi Irawan
    This document discusses the diagnosis and management of acute headaches in the emergency department. It presents two case studies, one involving a 40-year-old woman with sudden severe headache and another involving a 42-year-old woman requesting narcotics for a migraine. It then reviews the goals of headache management in the emergency department, which include excluding ominous causes, providing pain relief, minimizing time spent in the ED, and establishing follow-up care. The document emphasizes taking an accurate history and physical exam to establish a diagnosis when a patient presents with headache. It also discusses potential life-threatening etiologies, classification of primary versus secondary headaches, and treatment approaches in the emergency department.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd

    Diagnoses and Management Acute Headache Emergency Department

    Uploaded by

    Bendy Dwi Irawan
    30 views37 pages
    This document discusses the diagnosis and management of acute headaches in the emergency department. It presents two case studies, one involving a 40-year-old woman with sudden severe headache and another involving a 42-year-old woman requesting narcotics for a migraine. It then reviews the goals of headache management in the emergency department, which include excluding ominous causes, providing pain relief, minimizing time spent in the ED, and establishing follow-up care. The document emphasizes taking an accurate history and physical exam to establish a diagnosis when a patient presents with headache. It also discusses potential life-threatening etiologies, classification of primary versus secondary headaches, and treatment approaches in the emergency department.

    Original Description:

    io

    Original Title

    Headache

    Copyright

    © © All Rights Reserved

    Available Formats

    PPT, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document discusses the diagnosis and management of acute headaches in the emergency department. It presents two case studies, one involving a 40-year-old woman with sudden severe headache and another involving a 42-year-old woman requesting narcotics for a migraine. It then reviews the goals of headache management in the emergency department, which include excluding ominous causes, providing pain relief, minimizing time spent in the ED, and establishing follow-up care. The document emphasizes taking an accurate history and physical exam to establish a diagnosis when a patient presents with headache. It also discusses potential life-threatening etiologies, classification of primary versus secondary headaches, and treatment approaches in the emergency department.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    30 views37 pages

    Diagnoses and Management Acute Headache Emergency Department

    Uploaded by

    Bendy Dwi Irawan
    This document discusses the diagnosis and management of acute headaches in the emergency department. It presents two case studies, one involving a 40-year-old woman with sudden severe headache and another involving a 42-year-old woman requesting narcotics for a migraine. It then reviews the goals of headache management in the emergency department, which include excluding ominous causes, providing pain relief, minimizing time spent in the ED, and establishing follow-up care. The document emphasizes taking an accurate history and physical exam to establish a diagnosis when a patient presents with headache. It also discusses potential life-threatening etiologies, classification of primary versus secondary headaches, and treatment approaches in the emergency department.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 37

    Diagnoses and Management

    of
    Acute Headache
    in the
    Emergency Department
    Case I: 40 yo. F-brought to the ER by EMS, c/o severe
    HA. Describes HA as pounding in nature, diffuse, sudden
    onset, associated with N/V X 3 over the last several
    hours. Also c/o dizziness & blurry vision.
    PE: VSS-appears in moderate distress and remains
    recumbent on the examination table during the entire
    assessment. HEENT: PERRLA, EOMI but squints when
    testing pupillary response. Resists movement when asked
    to flex her neck and cries out when you attempt to assist
    her with neck flexion. Neuro exam: occasional slurring
    of speech and lethargy noted.
    Remaining of the Physical Exam is nl.
    Case II: 42 yo. F-presents to the ER stating that she is
    having a migraine and is requesting narcotics for pain
    relief. She has a long hx. of migraines and usually
    receives an IM narcotic and is discharged home. She
    would have talked to her FP for this but shes out of town.
    She was placed in urgent category by the triage RN
    because of stated degree of discomfort. She has received
    ergotamine and imitrex in the past w/out adequate
    response. Shes allergic to NSAIDs.
    PE: Sitting in a dark room with polarized sunglasses.
    Shes asking for pain relief and wondering aloud why you
    will not give it to her.
    Headache Is a Major Public Health
    Problem
    . Up to 4% of ED Visits / 2% All Office Visits
    . Over 20 Million Outpatient Visits
    . 78 % of Women and 60% of Men Experienced
    at Least One Headache in the Year
    . 36% of Women and 19% Men Suffered From
    Recurrent Headaches
    Potentially Life Threatening Etiologies
    Characterize Patients Presenting to the
    Emergency Department With a Chief
    Complaint of a Severe Headache
    in <5% of the Cases
    Goals of Headache Management in the
    Emergency Department

    Primary
    Exclude Ominous Causes
    Provide Adequate Relief of Pain
    Secondary
    Minimize Time Spent in the ED
    Establish Continuity of Care
    after discharge
    History
    Establishing a diagnoses when a patient
    presents with a headache depends almost
    entirely on taking an accurate patient
    history and physical exam
    Age of Onset

    Benign syndromes usually begin


    before middle age

    Ominous causes of headaches occur more


    frequently with advanced age
    (>40 years old)
    Duration of complaint
    . Sudden onset: SAH or meningitis
    . Gradual or chronic: Migraine, tension HA
    Recently developed over several days,weeks or months
    -New onset migraine or tension-type headache
    -Increased Intracranial Pressure
    -Temporal Arteritis
    Headache Location
    . helpful but nonspecific
    Unilateral: Migraine, cluster

    Bilateral/diffuse: Tension, Migraine

    Associated Symptoms
    . GI and Neurological symptoms most common
    example: eye pain, photophobia, N/V, syncope, fever,
    facial pain, jaw claudication, etc.
    . Aggravating or relieving
    factors

    . Family History: Migraine & SAH


    . Other History
    Medications
    Toxic exposures
    Trauma
    Hypertension
    HIV
    PHYSICAL EXAM
    Does the patient look ill?
    Vital signs: fever, BP
    HEENT & Neurological exams most important!
    Fundoscopic exam
    Cranial nerves
    Mental Status
    Meningeal irritation
    Gait and reflexes
    Tenderness on palpation
    In Summary.
    To what extend should each patient be evaluated?

    Absolute clinical indications


    Worst headache ever
    Onset associated with exertion
    Depressed cognition or neurologic deficit on exam
    Nuchal signs
    Deterioration during observation

    Conservative approach acceptable in patients


    Lack the above findings with normal VS
    Improvement during observation
    Investigating Headache
    Is any special investigation warranted?

    When there is diagnostic difficulty or history suggests a serious


    disorder, investigation becomes obligatory!

    CT-Scan
    MRI
    Lumbar Puncture
    Blood Count/ESR
    Headache Classification
    User friendly IHS Classification
    Primary Headaches
    Benign Headache disorders
    Migraine (with or without aura)
    Tension-type headaches
    Cluster headaches
    Drug rebound headaches-Medication overuse headache

    Secondary Headaches
    Headaches that are symptoms of organic disease
    Secondary Headaches
    Subarachnoid Hemorrhage
    Meningitis
    Temporal Arteritis
    Hypertension
    Glaucoma
    Trauma
    Non-meningitic Infections
    Pseudotumor Cerebri
    Metabolic Disorders
    Toxic Substances
    Space Occupying Lesions
    Sinusitis
    Subarachnoid Hemorrhage
    sudden onset HA unexpected clap of thunder
    most common location is occipitonuchal
    excruciating pain,vomiting, obtundation
    Diagnosis: CT-Scan, LP (xanthochromia)

    Treatment: Seizure precautions


    Nimodipine 60 mg. orally
    Monitor BP
    Neurosurgical evaluation
    Meningitis
    fever, stiff neck, mental status change
    headache worse with eye movement
    No papilledema or neurologic deficit seen
    Diagnosis: LP
    Treatment: start IV-Antibiotics immediately
    Temporal Arteritis
    usually over 50 yrs old
    severe, throbbing temporal headache, jaw
    claudication, tender temporal artery
    loss of vision due to optic neuritis
    Dx: age >50, new onset HA, Temporal artery
    tenderness, elevated ESR (>50), (+) biopsy
    Treatment: Steroids/Neurology consult
    Primary Headache Etiology ????
    Primary Headache
    Pathophysiology
    Hypotheses (specific cause unknown)
    -Cortical spreading definition
    -Migraine generator
    -Vasodilation/inflammation
    -Peripheral sensitization
    -Genetic factors
    -Others.
    International Headache Society Criteria
    for Migraine
    Migraine Is an Episodic Recurrent HA
    lasting 4-72 Hours With:

    Any 2 of these pain Any 1 of these


    qualities: associated
    . Unilateral pain symptoms:
    . Throbbing pain .Neusea and/or vomiting
    . Pain worsened by .Photophobia and
    movement
    phonophobia
    . Moderate or severe
    pain
    Primary Headaches
    Migraine Headache
    Currently 28 million migraine sufferers age 12+ in USA
    -21 million females
    -7 million males

    Migraine prevalence peaks in the 25-55 age group


    -25% of women aged 18-49 suffer from migraine

    1 in 4 households has at least 1 migraine sufferer


    Migraine with Aura
    due to primary neuronal dysfunction
    corresponding decrease in blood flow to the area
    visual auras most common
    flashing lights or dark spots
    lasts 30 minutes to one hour-fully reversible
    ->60 minutes, r/o underlying
    ischemic/coagulopathic/embolic disorders
    only seen in 15-20% of migraine patients
    Cluster Headaches
    Criteria for diagnoses: at least 5 attacks
    A. Severe unilateral orbital, supra-orbital and/or temporal pain
    lasting 15 to 180 minutes
    B. At least one of the following on the headache side;
    . Conjuctival injection . Lacrimation
    . Facial/forehead sweating . Miosis
    . Nasal congestion . Ptosis
    . Eyelid edema . Rhinorrhea
    C. Frequency: from one every other day to eight per day
    More common in males
    Treatment: Oxygen, Triptans, Ergots, Indocin, Steroids
    Chronic Tension Headaches
    A. Average frequency of attacks >15 days/month for 6 months
    B. At least two of the pain characteristics;
    1. Pressing/tightening (non-pulsating) quality
    2. Bilateral location
    3. Not aggravated by routine physical activity
    4. Mild/moderate severity

    C. Both of the following;


    1. No vomiting
    2. No more than one of the following: N, photophobia, phonophobia

    D. No evidence of organic disease


    Treatment of Benign Headache in the
    Emergency Department
    Parenteral Agents
    . Nonspecific analgesics: Narcotics
    . NSAIDs (Toradol)

    Neuroleptics/antiemetics
    . Phenothiazines (Thorazine, Compazine)
    . Metoclopramide (Reglan)

    Serotonin receptor agonists: Triptans, Dihydroergotamine


    Narcotics
    Widely used, esp. IM forms
    Should be avoided for 3 reasons;
    . Less effective, deals with pain, treating only a symptom
    . Sedating, respiratory depression
    . Abuse potential

    Most useful in elderly and selected pregnant patients


    Serotonin Receptor Agonists
    . Receptor specific agonists that stimulate serotonin (5-HT1)
    receptors to reduce neurogenic inflammation

    Dihydroergotamine (DHE)
    . Broader spectrum, affects serotoninergic,
    alpha-adrenergic and dopamine receptors
    Sumatriptan: Imitrex
    Others: Naratriptan(Amerge), almotriptan(Axert),
    rizatriptan(Maxalt), frovatriptan(Frova), eletriptan(Relpax),
    zolmitriptan(Zomig), etc.
    D.H.E
    Offers primary therapy, not just pain relief
    Minimal side effects, mainly N/V
    No physical dependence; non-narcotic
    may be administered IV, IM, SQ and NS available
    Venoconstrictor-has no arterial vasoconstrictor effects
    General precautions; age over 60, DM and HTN
    other side effects: leg cramps, chest tightness
    DHE
    IV/IM/SC: 0.25-1 mg., can be used 2-3x/day
    Nasal Spray: 1 spray in each nostril (0.5 mg/spray)
    may repeat in 15 mins (4 sprays=2 mg)
    use no more than 2-3x/week, on separate days
    Avoid use with macrolide antibiotics, in patients with
    ischemic heart dz, uncontrolled HTN
    Other ergotamine medications;
    Ergotamine tartrate(ET): cafergot, Wigraine, etc.
    available in oral, suppositories, sublingual(ergostat)
    2 tabs at onset, 1-2 q30-60 mins, max. 2-6/day
    no more than 2 days/week
    cannot be used within 24 hours of triptan medications
    Administration of D.H.E
    Method I: Pretreat with 10 mg IV compazine over 2 mins
    Wait app. 20 mins, administer 0.5-1.0 mg
    DHE-slow IVP over 2 minutes

    Method II: Draw 1 mg DHE and 2 ml of compazine


    in a single 3-ml syringe
    Administer through single venopuncture
    via 2 min. slow IVP

    Method III: may use IM, slower onset of action


    SUMATRIPTAN
    Serotonin receptor agonist but differs from DHE
    in 3 major respects;

    1. Does not require use of an antiemetic agent,


    has antiemetic properties of its own

    2. Available in a SC auto-injectable format containing a


    fixed 6-mg. dose and oral tablets

    3. Has a relatively short half life of about 2 hours

    Patient acceptance very high with SC, oral and NS


    SUMATRIPTAN

    SC dose: 6 mg. May repeat in one hour


    No more than 2 in 24 hours, limit 2 days/week

    Oral: 25-100 mg tabstake at onset, may repeat in 2 hrs


    max. 100 mg/day

    Nasal Spray: 5 or 20 mg. 1 spray in each nostril


    may repeat in 2 hrs, max. 40 mg/24 hrs

    Should not be used in patients with CV, cerebrovascular,


    severe HTN, severe hepatic impairment, angina or PVD.
    Do not take within 2 weeks of MAOI discontinuation
    SUMATRIPTAN
    Excellent migraine medication for select patients
    Works rapidly, minimal nursing time and side effects
    Recurrance of hadaches within 24 hrs-major objection
    to its use-may need repeat dose
    2 deaths linked to this medication;
    1. Woman with COPD
    2. Patient w/CAD had MI 6 days after its use
    No ECG changes documented with use
    Pregnancy category C
    DHE vs-Sumatriptan
    Both are highly effective in aborting headaches
    DHE-IV requires treatment with anti-emetics, RN time
    Imitrex may require repeat treatment within 2 hours
    Side effects: similar
    Cost: Sumatriptan injection app. $35/dose
    Nasal Spray: $ 35.00
    DHE-45 1.0 mg injection app. $ 18.00/dose
    Migranal NS: $ 43.00
    Narcotic Seeking Patients
    Demanding behavior
    List of allergies
    Unusual history and presentation
    Difficult to deal with

    You might also like