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New Onset Severe Headache When Should I Worry?

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New Onset Severe Headache When Should I Worry? New onset severe headache when should I worry? Dr Marc Randall Consultant Neurologist and Acute Stroke Physician Leeds Teaching Hospitals NHS Trust Honorary Senior Lecturer University of Leeds The simple answer from me Dear Mrs Smith Further to your attendance at hospital today I can confirm there is really nothing seriously wrong with you. With your history of migraine headache disorder, and no other signs or symptoms other than severe headache I am 98% certain that you do not have an aneurysm, brain tumor or stroke. This is why I did not waste too much time seeing you as I am sure you can appreciate I am very busy. You don’t need a scan and I don’t plan on wasting any of the tax payers money, or exposing you to unnecessary radiation just to stop you worrying. If I had wasted time scanning you on average we are statistically more likely to have discovered an incidental finding rather than any true causative pathology which would have added to your stresses. I realise your headaches are distressing but with the ridiculous waiting time for a follow up to see a neurologist they will probably have settled down in any case. If have asked your GP to give you some amitriptyline as you looked a bit fed up with your headaches. Kind regards Why is the patient worried ? Cerebral Bleed Aneurysm Tumour • Exclude a secondary headache. • Thunderclap • SAH • Positional • Raised intracranial pressure • Malaise What does serious • Meningitis mean to acute • Weight loss clinicians ? • Cancer • Not one of those = home ? Problem solved • 1) Worst most severe headache ever. So why are you here • 2) Lack of progress through other routes. ? • 3) Non specific symptoms one of them being headache. Age makes a difference : Frequency of pathological diagnosis by age group. JN Goldstein et al. Cephalalgia 2006;26:684-690 Copyright © by International Headache Society Features linked with pathology (n=15,062) Feature OR 95% CI Age > 50 7.26 (4.24 – 12.43) Arrival by Ambulance 3.66 (1.97 – 6.77) Sensory disturbance 6.04 (2.47 – 14.74) Speech disturbance 10.54 (3.92 to 28.30) Vision disturbance 3.02 (1.12 to 8.14) Motor disturbance 11.67 (2.50 – 54.49) Systolic BP > 160 2.34 (1.41 to 3.90) Diastolic BP > 100 1.98 (1.12 to 3.51) Neurological weakness 8.46 (2.29 – 31.23) John W Gilbert et al. Emerg Med J 2012;29:576-581 Final diagnosis documented for headache in US emergency departments. JN Goldstein et al. Cephalalgia 2006;26:684-690 Copyright © by International Headache Society P SNOOP4 – (4 P’s added 2010) Systemic • Unexplained fevers • Unexplained weight loss • Known malignancy • Immunosuppressed or HIV • Pathology • Tumours, Menningitis, Abscess, Arteritis Neurological • Motor weakness • Sensory loss • Diplopia • Ataxia • Pathology • Malignant, Inflammatory or Vascular disorders Onset sudden • Peak intensity in less then 1 minute • Pathology • Vascular (SAH, Stroke, Carotid Disection, Cerebral vasoconstriction syndrome, Venous thrombosis) Older • New onset headache over 50 • Change in pattern over age 50 • Pathology • Neoplastic, Inflammatory disorders, Temporal arteritis Pattern Change • The 4 P’s • Progressive • Malignant, Inflammatory, Vascular • Precipitated • Chiari, Hydrocephalus, Malignant • Postural • Intracranial Hyper / Hypo tension, Cervicogenic • Papilloedema • SOL , IIH, Venous thrombosis • Secondary headaches are more common in the emergency setting than GP. • Headache of sudden onset Will the red • Secondary cause in 21 – 43 % (less than flags help ? 10 secs) • SAH : 11.3 – 16.3 Well that % • Stroke : 3.6 % depends on • Intra cerebral bleed : 2.2 – 8 % the study. • Meningitis : 2.9 % • Cerebral Oedema : 0.7 % • Venous thrombosis : 0.7 % Some reassurance if none of the Snoop criteria fulfilled • Individuals with a known primary headache disorder, who present with headache. • CT scan will show as incidentals ! • Cerebrovascular disease 1.1% • Brain tumour 1 % (meningioma in most cases) • Hydrocephalus 0.3% • AVM 0.2% • Subdural Haematoma 0.2% • Aneurysm 0.1% Frishberg Neurology 1994 44:1191 - 97 Primary care data The big worry = Thunderclap headache • History has to be right. • Pathology can be missed if the pre test probability is low. • Incorrect / Over imaging may be a problem. • Being able to give a positive diagnosis decreases risks of missing pathology. • Some primary headache disorders will present as thunderclap if not treated appropriately can be serious. • Follow up is essential • Atypical migraine should not really be diagnosed in A & E R L What presents as a “thunderclap?” • Vascular disorders • Subarachnoid haemorrhage 10% • Subdural, extradural and intracerebral haemorrhage • Cerebral venous sinus thrombosis • Carotid and vertebral artery dissection • Acute cerebral ischaemia Don’t forget primary • Arterial hypertension headaches can • Pituitary apoplexy “thunderclap” • Reversible cerebral vasoconstriction syndrome • Non-vascular intracranial disorders • Spontaneous intracranial hypotension • Acute obstructive hydrocephalus It may just be primary thunderclap headache • A. Severe head pain fulfilling criteria B and C • B. Both of the following characteristics: • sudden onset, reaching maximum intensity in <1 min • lasting from 1 h to 10 days • C. Does not recur regularly over subsequent weeks or months • D. Not attributed to another disorder (normal cerebrospinal fluid and normal brain imaging are needed Thunderclap - +ve diagnosis CT CT + con CT and LP Further SAH CTA / MRA CVT / CTV / MRV Dissection MRA Acute hypertension (PRES) MRI Intra cranial hypo MRI + C Stroke MRI Pituitary Apoplexy MRI 3rd Ventricular Cyst MRI Intra cranial infection RVCS CTA/MRA/Ang Cough / Orgasmic / MRI Peri orbital face pain “not headache.” 39 yr old male neck pain, left eye pain, transient right arm weakness and left sided pupil abnormality 2 weeks later presents chronic headache. But onset was hyperacute. Dissection • Carotid/vertebral dissection in 50-100% • Headache and facial/neck pain • Usually ipsilateral to dissection. • May have thunderclap onset • Headache is sole presenting feature in 15% • Carotid dissection often associated with ipsilateral Horner’s syndrome with or without signs of cerebral ischaemia. • Vertebral dissection may be accompanied by signs of brainstem or cerebellar ischaemia. Acute onset headache language disturbance. • 55 yr old male sudden onset dysphasia with head ache no other neurological symptoms, dysphasia recovered within 24 hours. Thunderclap headache – 1st scan normal Then chronic headache “migraines” Angiogram showing vasospasm RVCS (Reversible vasoconstriction syndrome) • Includes a group of disorders ? up to 9% of thunderclap headache. • Recognized as separate from vasculitis. • Inc. Drug induced vasospasm, cannabis, cocaine, nicotine, nasal decongestant • 55 % initial plain CT or MRI no signs. • Thunderclap headache usually focal signs • 81% may develop later lesions. • Ischaemic stroke 39% • SAH 34% • Lobar bleeds 20% • Oedema 38% Intracranial hypotension • Up to 14 % of patients with intracranial hypotension present with acute severe headache • CSF Volume depletion as a result of leakage • Leak may be • Iatrogenic (post dural puncture, surgery. shunt) • Traumatic (basal skull fracture) • “Spontaneous” spinal dural tear (root sleeve) • - initial trauma may not be recalled Presentation (very variable) • Classic • Orthostatic • Throbbing or not • Frontal or occipito-nuchal (pulling sensation) • Usually bilateral (although unilateral known) • Can be preceded by hours or days by back , neck or intrascapular pain. • Orthostatic headache initially becomes chronic daily (loss positional element • Exertional headache • Thunderclap headache • Second half of day headaches • Paradoxical othostatic (usually chronic) Mokri 2004 Neurology Clinics Non headache symptoms have all been described • Tinnitus / muffled hearing • Neck pain • Positional vomiting • Diplopia (6th) • Facial numbness / weakness • Variable episodes of consciousness • Bulbar / extrapyramidal • Bladder disturbance Acute headache and confusion 69 year old lady recent fall, fractured pubic rami, headache and no comprehension. PRES Papilloedema (elevated pressure) Idiopathic intracranial hypertension • Not benign • Commoner in young women with high BMI (DDx sleep apnoea) • Presents with: • Headache (92-94%) of raised ICP • Papilloedema • Pulsatile tinnitus (64-87%) • Visual obscuration (may be absent) • Can be precipitated by: Vitamin A, Tetracyclines, OCP • Imaging - exclude sinus thrombosis IIH treatments CSF examination Treatment: (only for diagnosis) • pressure reduction by LP • Weight loss reduces pain • Acetazolamide / Topiramate • CSF Shunting may be necessary if vision threatened. Shunting no place to treat headache. • Venous stenting !!! 35 year old previous headaches on exertion and CT normal. Now acute headache and Papilloedema A good history, followed by review of the history, and retaking the history mean you will probably be safe 99% of the time. The main point being Also most of your patients will have a form of migraine so consider longer term support and referral. Prevalence of migraine = 12% in unselected population. The IHS criteria are very strict in defining of migraine. • 6 classifications A reminder on • 1 Without aura migraine if • 2 With aura • 3 Childhood periodic needed • 4 Retinal migraine • 5 Complicated • 6 Probable • Most of the acute patients we see and label their first severe headache as migraine should really have the diagnosis of probable migraine. To diagnose migraine • > 5 attacks
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