P1: KWW/KKL P2: KWW/HCN QC: KWW/FLX T1: KWW GRBT050-139 Olesen- 2057G GRBT050-Olesen-v6.cls August 17, 2005 3:52 ••Chapter 139 ◗ Headaches in the Emergency Room Dominique Valade INTRODUCTION for a patient suffering from an intense headache, 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 pain, 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, meningitis, 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 (migraine, 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. 1133 GRBT050-139P1: Olesen- KWW/KKL 2057G GRBT050-Olesen-v6.cls P2: KWW/HCN August QC: 17, KWW/FLX 2005 T1: 3:52 KWW 1134 TWO KEY QUESTIONS: DURATION? CIRCUMSTANCES OF ONSET? Special Problems in the Headaches and Their Management A RARE DANGER THAT MUST BE ROUTINELY CONSIDERED: WHEN TO ASK FOR ADDITIONAL INVESTIGATIONS LIFE-THREATENING HEADACHE 1 Sudden acute 23 Acute headache beginning in the Chronic headache present for a headache of recent onset previous days, weeks or months number of months or years including Thunderclap headache (very intense, very abrupt onset) Intracranial Temporal arteritis Consider first : hypertension or Horton Episodic headache Continuous headache - Sub arachnoidal hemorrhage (e.g cerebral venous disease - Unrupted vascular malformation: thrombosis) aneurysm - Cerebral veinous thrombosis ENT or Need for rapid, non-emergency MRA Meningeal syndroms ophthalmological origin Cluster headache Posttraumatic headache (e.g., glaucoma, acute sinusitis) General causes Carotid or vertebral artery dissection (fever with no other Migraine neurological symptoms) Chronic daily headache due to drug abuse Cerebral hematoma or infarction (symptoms generally dominated by focal neurological signs) Positional headache caused by low CSF pressure Tension headache (generally postlesional) Additional investigations required : - Key exams : CT scan, lumbar puncture. If modification: Hypertensive encephalopathy - If necessary : cerebral or cervical MRI, - Long-standing headache previously indentical for a duplex scanning, arteriography. long period (months, years) - Frequency, severity, or characteristics of episodes of headache Acute hydrocephaly Treatment on emergency if indication - Headache becoming gradual, daily, or persistent (induced by intraventricular tumors) FIGURE 139-1. Tw o key questions: What has been the duration of the headache? What were the circumstances of onset? CSF, cerebrospinal fluid; CT, computed tomography; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging. 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