ISG Headache

Top 10 Workups   6 1

HEADACHE

• How severe is the headache? Has there been a change in conscious- ness? Are there any new focal CNS symptoms? Has the patient had similar headaches in the past? If so, what precipitates or relieves them? • If the headache is severe and acute or associated with N/V, changes in vision, other focal CNS findings, fever, or decreased consciousness, the patient should be seen immediately. However, you may very well have a headache too, hopefully without any of these findings. Major Causes and Types of Headache • Subarachnoid hemorrhage • Tension • Migraine • Cluster • Medication side effect • Temporal arteritis • Infectious (meningitis, sinusitis, fever, in general) • Trauma • CVA • Severe hypertension (HTN) • Mass lesions Things You Don’t Want to Miss (Call Your Resident) • Meningitis • CVA • Subarachnoid hemorrhage or subdural hematoma • Mass lesion associated with herniation Key History • Check vitals: BP, pulse, respirations, O 2 saturations, and temperature. • Quickly look at the patient and review the chart. • A detailed, well-focused history is the best method for evaluating a headache. Most are tension or migraine type, but more serious conditions need to be ruled out.

6 2   INTERNSHIP SURVIVAL GUIDE

Focused Examination General

Does the patient appear ill or distressed?

HEENT

Look for signs of trauma, pupil size, symmetry, response to light, papilledema, nuchal rigidity, tem- poral artery tenderness, and sinus tenderness. Thorough examination is mandatory, including men- tal status.

Neurologic

Laboratory and Diagnostic Data • Consider CBC and erythrocyte sedimentation rate if temporal arteritis is suspected. • Head CT should be considered for the following: • A chronic headache pattern that has changed or a new severe headache occurs • A new headache in a patient older than 50 years • Focal findings on neurologic examination • If meningitis is suspected, an LP should be performed! Obtain a head CT before LP in the following: elderly, immunocom- promised, in the presence of seizures, those with altered level of consciousness, and those with focal neurologic abnormalities (see Chapter 22, Neurology). Management • The initial goal is to exclude the serious life-threatening con- ditions mentioned previously. After such conditions have been excluded, management can focus on symptomatic relief. • For suspected bacterial meningitis, start antibiotics immediately (do not wait for an LP; see Chapter 22, Neurology). • For suspected subdural hematoma or subarachnoid hemorrhage, obtain CT scan. If positive, a neurosurgery consultation should be obtained. • Tension headaches and mild migraines can be treated with acet- aminophen 650 to 1000mg PO q6h PRN or ibuprofen 200 to 600mg PO q6-8h. • Consider sumatriptan 25mg PO for moderate to severe migraine headaches; can repeat 25 to 100mg q2h for maximum of 200 to 300mg/d. This therapy is most effective when given immediately after the onset of headache. Avoid use in patients with angina or uncontrolled HTN. • IV ketorolac and prochlorperazine are often used in the hospital for abortive therapy for headache.