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••Chapter 139

◗ in the Emergency Room

Dominique Valade

INTRODUCTION for a patient suffering from an intense , but can be manageable in a quiet, dark room. During the inter- In emergency departments (7,8), the top priority is to es- view the physician should attempt to ascertain the dura- tablish a precise etiologic diagnosis and to classify the tion since headache outset, the characteristics of the , headache as a primary headache, a benign secondary and the circumstances of and symptoms associated with headache, such as from influenza, or a secondary headache onset (Fig. 139-1). due to a serious condition, requiring further exploration or emergency treatment (meningeal hemorrhage, , intracranial hypertension) (2,6). The crucial part of this Duration Since Onset and diagnostic step is the interview. This step, supplemented Evolutionary Profile by the clinical examination, will determine the diagnosis and, ultimately, the course of treatment, which is usually The following questions can assist the physician in classi- conducted on an outpatient basis for primary headache. fying the headache: For benign secondary headache, further diagnosis may be necessary, but can be continued on an outpatient basis. How did the headache begin? (sudden or progressive Finally, emergency diagnosis and treatment in the hospi- onset) tal setting may be necessary for secondary headache with How long have you had this headache? (acute or chronic serious underlying causes. headache) The physician must also identify headaches occurring Have you ever had this type of headache before? (unusual in patients already hospitalized for another reason. It is cephalgia or a new attack of a known headache pattern) important to rule out any iatrogenic causes such as drug- How has the pain changed since the onset of the head- induced headaches or headaches caused by hypotension ache? (spontaneous improvement, became worse, or re- of the cerebrospinal fluid (CSF), such as secondary to a mained the same) persisting fistula. Based on the answer to these questions, the headache Finally, some patients diagnosed with a primary head- can be classified as one of four types: ache may sometimes require hospitalization either be- cause of an acute exacerbation of their primary headache Sudden acute headache in a particular psychologic context, or,especially,for detox- Unusual new headache, beginning in the previous days, ification for chronic daily headache associated with drug weeks, or months abuse. Paroxysmal chronic headache (, cluster head- ache) STEPS IN THE INITIAL DIAGNOSIS OF Chronic tension-type headache or chronic secondary head- AHEADACHE SEEN IN THE ache EMERGENCY ROOM The principal arguments for further diagnostic in- vestigation are headache pain of recent onset, a new Obtaining a History of a Patient occurrence of fast or sudden onset, or, in a patient Who Presents With Headache with a history of primary headache (migraine or tension The first step in the diagnosis of headache is to obtain a headache), a pain that is totally different from the usual history from the patient by interview. This can be difficult headache.

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1134 Special Problems in the Headaches and Their Management

of episodes

due to drug abuse Tension headache Chronic daily headache Posttraumatic headache If modification: number of months or years Chronic headache present for a Migraine Episodic headache Continuous headache Long-standing headache previously indentical for a Frequency, severity, or characteristics Headache becoming gradual, daily, or persistent headache - - - long period (months, years) disease ENT or or Horton HEN TO ASK FOR ADDITIONAL INVESTIGATIONS General causes Temporal arteritis (fever with no other W neurological symptoms)

ophthalmological origin

(e.g., glaucoma, acute sinusitis)

Treatment on emergency if indication previous days, weeks or months Acute headache beginning in the thrombosis) Intracranial hypertension (e.g cerebral venous Meningeal syndroms Key exams : CT scan, lumbar puncture. If necessary : cerebral or cervical MRI, 23 Additional investigations required : - - duplex scanning, arteriography. key questions: What has been the duration of the headache? What were the Tw o : TWO KEY QUESTIONS: DURATION? CIRCUMSTANCES OF ONSET? FIGURE 139-1. circumstances of onset? CSF, cerebrospinal fluid; CT,angiography; computed tomography; MRI, MRA, magnetic magnetic resonance resonance imaging. pressure neurological signs) Sudden acute Acute hydrocephaly (generally postlesional) THREATENING HEADACHE - Hypertensive ROUTINELY CONSIDERED (induced by intraventricular tumors) Cerebral hematoma or infarction RARE DANGER THAT MUST BE Sub arachnoidal hemorrhage Need for rapid, non-emergency MRA including IFE headache of recent onset - - Unrupted vascular malformation: aneurysm Carotid or vertebral artery dissection (symptoms generally dominated by focal L A

Positional headache caused by low CSF 1 (very intense, very abrupt onset) Consider first : - Cerebral veinous thrombosis P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-139 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 3:52

Headaches in the Emergency Room 1135

Characteristics of the Pain meningeal syndromes, such as intracranial hypertension, but are also associated with migraine. The absence of any The intensity of the pain does not give any indication for a associated symptoms does not eliminate a diagnosis of sec- diagnosis of primary or secondary headache. Nevertheless, ondary headache and should not postpone the initiation of any sudden and severe headache (thunderclap headache) additional examinations if the headache is recent, unusual, must be regarded as secondary and further explored in the and persistent. emergency department. It is important to consider the cor- relation between the intensity of the pain described by the patient and how the pain impacts his or her attitude (e.g., Clinical Examination does he or she require bed rest, difficulties in expressing In addition to a general examination including blood pres- himself or herself). The type of pain can be very variable sure and temperature, a clinical examination should in- (pulsatile, continuous, “electric shock,” crushing, pressure, clude a neurologic and physical examination. Any abnor- only discomfort) but may not be specific to a particular mality in either the neurologic or physical examination in- etiology. Topography can sometimes be an indication of dicates the need for further evaluation. On the other hand, a specific disease, such as the temporal pain of Horton’s a strictly normal clinical examination does not eliminate disease, but is usually not specific to a particular etiology. the possibility of a serious cause and should not preclude laboratory investigation. Circumstances of Onset The circumstances surrounding the onset of a headache Neurologic Examination can sometimes guide the physician to an immediate diag- Initially, the neurologic examination considers state of nosis: cranial trauma (hemorrhage or cerebral contusion), consciousness and cortical function of the patient and ex- medication or drugs recently taken, a lumbar puncture, re- plores the possibility of a meningeal syndrome. Then, the cent peridural (epidural) or spinal anesthesia causing CSF physician should check for a focal deficit that the interview hypotension, fever associated with general disease, etc. could have missed. The physician should then examine the However, the circumstances surrounding onset can also eyelids and the pupils for signs of Claude-Bernard-Horner, be misleading: An exertional headache can be benign which can indicate dissection of the internal carotid artery but also a symptom of a meningeal hemorrhage, and a or unilateral mydriasis caused by compression of the third headache after lumbar puncture is generally a headache cranial nerve by an aneurism of the posterior communicat- caused by hypotension of the CSF but can sometimes sig- ing artery,and rule out a cerebellar syndrome such as static nal a cerebral venous thrombosis (1). cerebellar ataxia, which can go unnoticed in a patient ly- ing down. The physician should also check for anomalies Medical History of the visual field, such as left-side homonymous hemi- anopia of a right occipital lesion in a right-handed patient A patient’s medical history must be obtained in a system- who complains only about headaches. Finally, the physi- atic way because it may qualify the diagnosis. Cardiovascu- cian should conduct a funduscopic examination to check lar disease and hypertension (AVC), postpartum or venous for papillary edema or hypertensive retinopathy, possibly thrombosis of the lower limbs, cerebral venous throm- indicating hypertensive encephalopathy. bosis, neoplasy (metastases), immunosuppressed patients with HIV (cerebral toxoplasmosis), anxiety and depres- sion (decompensation with tension headache), and con- Physical Examination sumption of psychotropic drugs can all affect headache The physical examination should include palpation of the diagnosis. temporal arteries; examination for unusual sinus pressure, redness of the eyes, and exophthalmia or swelling of the eyelids; palpation of the eyeballs; and, finally, auscultation Associated Symptoms for inspiratory and expiratory breath patterns. It is also Any recent and unusual headache associated with a neu- important to palpate the cervical and chewing muscles, rologic symptom, such as loss of consciousness, epilep- which are very often contracted and painful in the case of tic , or focal signs, should always be assumed to a tension-type headache. be due to an intracranial lesion until proven otherwise. A headache with deterioration of health or claudication of Strategy of the Diagnostic Evaluation the jaw in a patient of more than 60 years of age should im- mediately point to a possible diagnosis of Horton disease. The usual blood examinations are seldom conclusive, ex- On the other hand, nausea, vomiting, , and cept for an increase in the sedimentation rate, which indi- phonophobia are nonspecific symptoms associated with cates temporal arteritis or an infectious state. P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-139 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 3:52

1136 Special Problems in the Headaches and Their Management

Any recent headache that is unusual and persistent, Magnetic Resonance Imaging whether of sudden or progressive onset, requires two ba- and CT-Angiography sic examinations to be carried out in a systematic way: the The MRI is the diagnostic tool of choice for diagnosing computed tomography (CT) scan without contrast injec- cerebral venous thrombosis, which can begin with an acute tion and a lumbar puncture (LP) (5). monosymptomatic headache with normal CT scan and lumbar puncture. Computed Tomography Scan The CT scan is the first examination to be conducted look- Conventional Cerebral Angiography ing for the presence of blood either in the subarachnoid It is indicated in the event of acute headache in only two spaces, or in the cerebral or cerebellar parenchyma. It can cases: also show or localized edema indicating an expansive lesion (tumor or abscess) and will then have to Meningeal hemorrhages in which the angiography must be further investigated later by CT scan with injection or be conducted by an intra-arterial method to diagnose a magnetic resonance imaging (MRI) (5). If there is a possi- possible ruptured or endovascular aneurism bility of acute sinusitis, a scan of the sinuses can be use- Sudden and severe headache, which is nonregressive, ful. A normal CT scan does not preclude an organic cause: when all preceding examinations are normal. It is not 5to10% of meningeal hemorrhages, 30% of cerebral ve- always possible to formally exclude a cerebral venous nous thrombosis, many cases of cervical arterial dissection thrombosis, an arterial dissection, or angiopathies of with only headache or some local signs, and many cases the arteries of middle gauge. An MRA or an angioscan of meningitis have normal CT scans, requiring continued can be conducted first, possibly followed by intra- investigation. arterial angiography. This last examination is often the only one able to clearly show irregularities, “string and beads,” of a reversible acute cerebral angiopathy; this Lumbar Puncture can also present as one or more episodes of thunder- clap headache, even when the CT scan, LP and MRI are The LP should follow a CT scan for each headache that normal. is unusual or of sudden or progressive onset, with a nor- mal CT scan, to search for blood or meningitis, even in the absence of meningeal syndrome. In some cases, LP can TREATMENT be indicated first if there is fever and normal conscious- ness in the absence of focal neurologic signs, in the event We mention only in this chapter the treatments that are of a possible meningeal hemorrhage, or if a CT scan is carried out in the emergency room. not available or normal. It is essential to measure the CSF In cerebral sinus or venous thrombosis the leading pressure. Intracranial hypertension with normal CT scan symptom is headache in 80% and thunderclap headache requires checking for a cerebral venous thrombosis or a in 25% of patients. It is very important to have an early dural rent. diagnosis to start heparin therapy to improve conscious- ness and resolve neurologic function. At the beginning an epileptic strategy should be initiated to prevent . Transcranial Doppler and Extracranial The correlation of cervical pain, headache, and is- Duplex Scanning chemic signs is characteristic of dissection of carotid This examination must be conducted immediately each or vertebral arteries, and anticoagulant therapy must be time the clinical picture indicates a possible carotid or ver- rapidly administered to prevent embolism unless the dis- tebral artery dissection. The dissection can appear as an section extends intracranially. acute unilateral headache, sometimes isolated, but gen- If there is an acute posttraumatic headache, in particu- erally associated with local signs such as painful Claude- lar with epidural hematoma, immediate trepanation of the Bernard-Horner, tinnitus, paralysis of the last cranial skull is the treatment of choice nerves, or signs of retinal or cerebral . Echocagra- Various treatments have been used for patients with phy can visualize a hematoma in the arterial wall in spontaneous CSF leaks, but there is not one definite ap- which duplex ultrasound evaluates the possible hemody- proach (4). Some patients, fortunately, improve sponta- namic repercussion. However, these two examinations can neously. Bedrest and increased fluid intake have been be strictly normal, particularly in the purely cephalalgic advocated. The effectiveness of caffeine has been shown forms, either when the dissection affects portion of the in some studies, but durable beneficial effect is doubtful. arteries, or when it does not involve a significant arterial The efficacy of steroids has not been established. How- stenosis. The diagnosis must then be verified by MRI with ever, there is no control study. Autologous epidural blood magnetic resonance angiography (MRA). patch (EBP) can be considered as the best treatment. In P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-139 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 3:52

Headaches in the Emergency Room 1137

emergency, if diagnosis is certain, the importance of tramascularity, subcutaneously, or intraveneously) (DHE headache could justify EBP immediately. The recom- 1 mg/mL). mended target volume is 20 mL (9), but more seems to Either metoclopramide or metopimazine in supposi- be optimal; the duration of decubitus after the procedure tory form or by injectable route must always been admin- is 2 hours and the patient could quickly go back home. istered in combination with therapy. For , response to an EBP may occur When specific antimigraine drugs are not effective, pref- within minutes, whereas a more permanent delayed re- erence should be given to the parenteral route of adminis- sponse occurs within hours or days and results from defini- tration. Depending on individual habits and types of med- tive sealing of the leak. The success rate is less (30%) than ication previously taken by the patient for treatment of for post-LP headache for two reasons: the level of the leak attack, the following can be administered: may be distant from the level of the EBP, and the nature and anatomy of the leak are much different from a simple 1gparacetamol (acetaminophen) over a short 20-minute hole. If a delayed response is absent, EBP can be repeated, intravenous infusion in the absence of excessive self- sometimes after confirmation of CSF leak, to target the medication with (acetaminophen) EBP as close as possible to the level of leak. In well-selected in infusion under the same conditions as par- cases, surgical intervention can be tried when conservative acetamol approaches have failed (3). nefopam in infusion under the same conditions as de- When is suspected, an erythrocyte scribed above sedimentation rate or a C-reactive protein test must be A 20- or 50-mg ampule of clorazepate dipotassium can performed. Sometimes they might be very high and some- be added to infusion depending on the patient’s anxiety times they may be normal. Nevertheless, to avoid visual condition; in case of nausea or vomiting, a 10-mg ampule loss, treatment with steroids should be started as soon as of metoclopramide can also be added. the diagnosis is suspected and always before results of ar- In the event of failure of the abovementioned infusions, terial biopsy. or in case of excessive use of medicinal products not al- Patients with acute angle closure glaucoma present with lowing the use of the abovementioned drugs, 50 mg of pain localized to the eye and radiating to the ear, sinus, and and 1 mg/mL clonazepam can be admin- teeth. The intraocular pressure must be measured, and the istered, especially if the acute attack is accompanied by treatment is with miotics such as systemic acetazolamide, tension-type headache. Amitriptyline and clonazepam are pilocarpine, or eye drops of β−. infused slowly over approximately 2 hours, after informing Acute sinus infections are often easy to diagnose be- the patient that, as a result of the sedative effect of these cause the headache is associated with nasal obstruction, drugs, it will be necessary for him or her to be escorted fever, and localized tenderness; however, sphenoidal si- home by another person. nusitis may be painful without associated signs. To avoid In case of status migrainosus, the patient should be hos- intracranial complications, immediate antibiotic and anti- pitalized to continue this treatment. In case of excessive congestant therapy is mandatory and, if appropriate, sinus use of medicinal products, withdrawal should be planned drainage may be carried out. in a second phase. During migraine attack, it frequently occurs that a pa- For pregnant or nursing women, paracetamol by intra- tient comes to the emergency department without having venous route is prescribed as first-line therapy in patients taken any treatment, and then it may be sufficient to ini- who are not excessive users of . In the event of tiate therapy with a single 1-g oral dose of or even treatment failure or daily chronic headache, oxygen deliv- with a nonsteroidal anti-inflammatory drugs (NSAID), ei- ered via face mask at a rate of 10 L/min for 30 minutes may ther by oral route or, in case of vomiting, in suppository be administered. form. Metoclopramide or metopimazine in suppositories In addition to simple analgesics, which most often or by IV administration is given in combination with the would have been given to the child by his or her parents above mentioned drugs if serious vomiting is present. before arrival in the emergency department, the recom- If the patient has already taken aspirin, an NSAID, mended first-line therapy in young children is as follows: or paracetamol (acetaminophen) possibly combined with caffeine, codeine, or even dextropropoxyphene, the use of 20 mg/mL : 0.5 mL/kg (i.e, 10 mg/kg of body a specific antimigraine therapy is indicated, preferably by weight, starting from age 6 months) nasal or subcutaneous route, as follows: diclofenac 25-mg suppositories starting at 16 kg body weight (i.e, children over 4 years of age) 20 mg sumatriptan nasal spray 275 mg starting at 25 kg body weight (i.e, chil- 6 mg/0.5 mL subcutaneous sumatriptan dren over 6 years of age) In cases of known allergy or contraindication to trip- paracetamol (acetaminophen) alone in combination with tans, it is possible to use dihydroergotamine (DHE) ei- metoclopramide under the same conditions as de- ther by nasal route (DHE spray) or injectable route (in- scribed above P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-139 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 3:52

1138 Special Problems in the Headaches and Their Management

ergotamine tartrate: 1 tablet in children over 10 years of The tension-type headache patients need emergency age, never exceeding the dose of 6 tablets/week medical advice when the intensity of the pain is modified or sumatriptan 10 mg nasal spray starting at 35 kg body when the outcome is chronic daily headache; tranquilizers weight (i.e, over 12 years of age) such as lorazepam or muscle relaxants such as clonazepam may be attempted first and a follow-up with a neurologist The rectal route or nasal spray should be given prefer- must be recommended. ence in the event of gastrointestinal disorders. A child presenting with migraine disease should receive relaxation therapy as soon as possible. REFERENCES Management of migraine disease in an emergency de- partment requires a careful interview and a rigorous phys- 1. Benzon HT, Iqbal M, Tallman MS, et al. Superior sagittal sinus throm- ical and neurologic examination of the patient to avoid bosis in a patient with postdural puncture headache. Reg Anesth Pain Med 2003;28(1):64–67. overlooking any potential secondary headache. Treatment 2. Boulan P, Ducros A, Berroir S, et al. Les c´ephal´ees aigu¨es,dans Ur- of the attack, adjusted to previous therapies, contraindi- gences Neurologiques. Niclot P and Amarenco P, Editeurs. Paris: Da cations, and any excessive use of medicinal products, will Te Be Editions, 2001:13–26. 3. Mokri B. Headache associated with abnormalities in intracranial be offered to the patient. In the aftermath of the attack, structure or function: low cerebrospinal fluid pressure headache. In: the patient should be managed and in particular should Siberstein SD, Lipton RB, Dalassio DI, eds. Wolff’s headache and other consult his or her family doctor or a neurologist. head pain.7th ed. New York, 2001. 4. Mokri B, Piepgras DG, Miller GM. Syndrome of orthostatic headaches Even if the cluster headache attacks are short-lived, they and diffuse pachymenigeal gadolinium enhancement. Mayo Clin. Proc present very often to the emergency room for a lot of rea- 1997;72:400–413. sons: last subcutaneous sumatriptan used during the night, 5. Prager JM, Mikulis DJ. The radiology of headache. Med Clin North Am 1991;75(3):525–544. more than two attacks during 24 hours, such as six or seven 6. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of in- treated with sumatriptan in the same day, and accentua- tracranial pathologic findings in patients who seek emergency care tion of the number of attacks since some days. Oxygen because of headache. Arch Neurol 1997;54(12):1506–1509. 7. Rapoport AM, Silberstein SD. Emergency treatment of headache. Neu- should always been administered first even when it has rology 1992;42[3 Suppl 2]:43–44. been tried previously, and sometimes intranasal lidocaine 8. Silberstein SD. Evaluation and emergency treatment of headache. may be effective. Finally, to try to stop the increase of at- Headache 1992;32(8):396–407. 9. Szeinfeld M, Ihmeidan IH, Moser MM, et al. Epidural blood patch: tack frequency, 1 g of intravenous hydrocortisone may be evaluation of the volume and spread of blood injected into the epidural tried. space. Anesthesiology 1986;64:820–822.