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DEPARTEMENT
Troeboes Poerwadi
Departement Neurology
Dr Soetomo General Hospital
Airlangga Medical School
1
Introduction
Headache
is a nearly universal
experience
Top complaints in PHC
Some is serious health concern
Life time prevalence of headache: 93%
Severe headache impacting :20%
population
2% of all visits in ED
2
Differential Diagnosis of
Headache
I.
a.
b.
c.
d.
II.
a.
b.
c.
d.
Primary Headaches
Migraine
Cluster
Tension type
Other benign headache
Secondary Headaches
Head/neck trauma
CVD
Intracranial tumor
Intracranial infection
Differential Diagnosis of
Headache
II.
e.
f.
g.
h.
i.
Increased intensity
Increased frequency
Change in quality
6.
Headaches that worsen with the Valsava maneuver or
changes in posture
11
ED Evaluation - History
1.
2.
12
ED Evaluation - History
1.
2.
3.
4.
5.
ED Evaluation - History
6.
7.
8.
9.
10.
ED Evaluation Physical
Examination
Quick Look Test
Does the patient look well (comfortable),
sick (uncomfortable), or critical (about to
die ?)
Airway and Vital Signs
What is the temperature?
What is the blood pressure?
What is the pulse rate?
15
ED Evaluation Physical
Examination
Selective History and Chart Review
1. What is quality of pain?
2. Where is the located?
3. What time of day do the headaches
occurs?
4. Do warning symptoms occurs before
the headaches begin?
16
ED Evaluation Physical
Examination
Selective History and Chart Review
5.
Do any factors precipate the headaches and what
makes better?
6.
Are any symptoms or associated condition or risk
factor associated with headache?
7.
Is there a history of chronic or recurring
headaches?
8.
Are other any other associated symptoms with
these headaches? ( detailed under Primary
Headache Disiorders)
9.
Do headaches run in family?
17
ED Evaluation Physical
Examination
1.
2.
ED Evaluation Physical
Examination
3.
Neurologic Examination
Level of consciousness
Confussion or disorientation
Pupil symmetry
Papil edema and spontaneus venous pulsations)
Retinal hemorhages (flame or subhyloid)
Pronator drifts
Deep tendon and plantar reflexes
Gait
19
Diagnostic Testing
CT scan:
Acute, extremely severe headache (thunderclap
headache)
Papil edema
CT scan: useful in presentations involving trauma or
abrupt headache, acute fracture & hematoma are
best visualized by CT
1.
20
Diagostic Evaluation
2.
3.
MRI scanning
Greater sensitivity&capability of
visualization of the sinuses, posterior fossa,
skull base and preferable for all subacute or
chronic presenta-tions of headache
MRa
May be added in cases where vascular
dissection, malformation, occlusion, or
aneu-rysm is suspected
21
Diagnostic Evaluation
4.
Lumbar puncture
Mandatory in cases possible SAH (whwn
neuroimaging alone is only 90%)
Infectious
Neoplastic meningoencephalitis
Pseudotumor cerebri
CSF should be sent for:cell count, protein,
glucosa, cultures, cytology or special
studies
22
Diagnostic Evaluation
4.
Lumbar puncture
Ct scanning prior to LP is mandatory in
patients with depressed level of consciousness, neurologic focality, papil-ledema
or AIDS, because of the high likelihood of
detecting mass lesion in these patients.
Empirical Rx of suspected meningitis:
ceftriaxone 1 g IV every 12 hours and ampicillin IV 2 g every 6 hours
23
Diagnostic Evaluation
5.
Serum studies
Complete blood count: indicated on patients
with fever, meningismus, or suspected anemia
Erythrocyte sedimentation rate(ESR) should be
check in all individual > age 50 with or different
headache
Carboxyhemoglobin level CO exposure
Arterial blood gases (ABGs) should be
performed in cases hypoxia, hypercapnia or
acidosis
24
Diagnostic Evaluation
EKG and EEG are indicated in cases
headache with any loss of consciousness
7. In cases suspected ocular etiology:
consult to opthalmologist
6.
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Bilateral
No nausea or vomiting
Photophobia and phonophobia are absent, or one but not the other
is present
53
54
Cluster headaches
IHS Diagnostic Criteria
55
Cluster headaches
1.
Episodic cluster headache:occurs in periods
lasting 7 days to 1 yr, separated by pain-free
periods lasting >14 days
2.
Chronic cluster headache: occurs for > 1 yr
without remission or with remissions lasting < 14
days
56
Cluster headaches
Additional Features
57
58
B.
Migraine Headaches
IHS Diagnostic Criteria
Migraine without Aura
. A.>5 attacks fulfilling criteria B-D
.B.Untreated or unsuccessfully treated headache that last 4-72
hrs
.C.Headache with .2 of the following characteristic:
Unilateral
Pulsating quality
Moderate or severe intensity (interference with daily activities)
Aggravated by routine physical activity (eg.walking up stairs)
59
B.
Migraine Headaches
IHS Diagnostic Criteria
Migraine without Aura
. D.During headache,>2 of the following:
60
B.
Migraine Headaches
IHS Diagnostic Criteria
Migraine Aura
. A.> 2 attacks fulfilling criterion B
. B.> 3 of the following four characteristics:
61
B.
Migraine Headaches
IHS Diagnostic Criteria
Migraine Aura
. C. > 1 of the following:
62
Migraine Headaches
IHS Diagnostic Criteria
Less Common Variants
63
Migraine Headaches
Migraine Phases
Prodorme
64
B.
Migraine Headaches
Migraine Phases
Aura
Visual:
o
o
o
o
65
Migraine Headaches
Migraine Phases
Other common symptoms:
Aphasia
Dysarthria
66
B.
Migraine Headaches
Headache Phases
Pain:
o
67
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69
The headache attacks are shorter (average duration 12 minutes) and much more frequent, with attacks
occuring on avarage 14 times per day
70
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72
Patients self medicate throughout the day, often every 3-4 hrs, since
after that time headache generally worsens as analgesia begins to
wear off
73
Ergot has been shown to be active within the CNS, which may
result in a pharmacological dependence
74
May require supportive care for some days upon cessation of therapy
May need fluid replacement, use of anti-emetics, hypnotics and sedatives for
up to 14 days
75
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Algorithme
77
Algorithme
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Algorithme
79
Algorithme
80