I have a primary headache, and the only cure is...
These three classes of medications are first-line for classic migraine treatment.
NSAIDs (Ketorolac 15mg IV/IM x 1)
Dopamine Antagonists (Metoclopramide 10mg IV x 1)
Triptans (Sumatriptan 50-100mg PO x 1)
80% of nontraumatic SAH’s are caused by this etiology
This ocular finding may be present in Central Venous Thrombosis, as well as other causes of increased intracranial pressure.
Papilledema
A 35 year old female G1P0 at 32 weeks GA presenting with a new severe headache should prompt the following immediate investigation.
Blood Pressure measurement
(SBP > 160 mm Hg or DSB > 110 mm Hg)
This headache worsens when upright, improves when supine, and may be treated with... caffeine or blood? Yuck!
Post–Dural Puncture Headache
The role of this medication/dose/route is not abortive but to prevent recurrence of migraine.
Dexamethasone 10mg IV/IM
This is the next step after a non-con CT Head you ordered for SAH after 8 hours onset returns normal.
LP for Xanthochromia OR further imaging (CTA / MRI) (equally sensitive)
This partial syndrome is seen in 25% of carotid artery dissections due to stretch of sympathetic fibres travelling along the internal carotid.
Partial Horner Syndrome: ptosis, miosis, but no anhidrosis.
From the Greek "to disable by a stroke", this should be on the differential for a post-partum woman who presents with thunderclap headache, loss of visual field/diplopia and alerted LOC.
Pituitary Apoplexy
Diagnose with MRI > CT
Consider adrenal insufficiency, treat with hydrocortisone.
When considering headaches in the setting of hypertension, Rosen's suggests you should consider pre-eclampsia, intracranial hemorrhage, and this more nebulous entity:
This simple intervention will actually abort 80% of cluster headaches in 15 minutes.
High flow O2 at 15L/min via NRB
After diagnosis of SAH, these are the target BPs (upper, lower) and the IV medications used to achieve them:
SBP<160; 95<MAP<130
Labetalol / Nicardipine
Thunderstorm? This diagnosis presents as a series of thunderclap headaches usually triggered by exertion, Valsalva, sexual activity, emotional stress, or vasoactive substances.
Reversible Cerebral Vasoconstriction Syndrome
No babies allowed here: Name a toxin, a substance, and a medication cause of headache.
Carbon Monoxide, Cocaine, Nasal Decongestants
This measurement should be taken in a patient presenting with unilateral headache involving the eye, blurry vision, and conjunctivitis.
Intraocular Pressure >30mmHg for Acute Angle Closure Glaucoma
These are three example symptoms classic of cluster migraine:
Lacrimation
Rhinorrhea
Ptosis
Miosis
Forehead/facial sweating
Pain: unilateral sharp stabbing pain
These four risk factors associated with SAH
Age (40-60)
HTN
Smoking
EtOh
Sympathomimetic drugs
Genetic: ADPCKD, Marfan, Ehlers Danlos
As opposed to carotid artery dissections, vertebral artery dissections may present with this constellation of neurologic findings.
1. Wallenberg Syndrome: dysmetria, ataxia, ipsilateral hemiplegia and contralateral loss of pain and temperature sensation.
OR
2. Posterior circulation stroke syndromes: vertigo, diplopia, visual field deficits.
The following 3 agents are recommended antihypertensives in the setting of pre-eclampsia.
Labetalol 20mg IV
Hydralazine 5-10mg IV
Nifedipine 10mg IV
Diagnostic criteria for Idiopathic Intracranial Hypertension include this measurement for CSF opening pressure in adults.
>250 mm in adults
>280 mm in children
An injection of 0.5% bupivacaine ⅓ distance between the occipital protuberance and the mastoid process creates this effective treatment for migraines that fail first-line therapy.
Greater Occipital Nerve Block
A patient presents stuporous, with dense hemiparesis, is subsequently diagnosed with SAH. This scale is used to represent their clinical grading, and their presentation corresponds to a scale of:
Hunt and Hess Score: 4
Three of these five diagnostic criteria are required to diagnose Giant Cell Arteritis
1. Age ≥ 50
2. New headache type, particularly in association with visual loss or jaw claudication
3. Temporal artery tenderness or tenderness of other extracranial arteries
4. ESR ≥ 50 mm/h or CRP ≥ 10 mg/L
5. Positive imaging finding (US/MRI) or temporal artery biopsy
The new ACOG definition for Pre-eclampsia is...
Hypertension >140/90 x 2 /4h or >160/110 x 1 AND
Proteinuria (Protein:Cr 0.3mg/dL) OR
ANY OF SEVERE FEATURES: Thrombocytopenia, Renal Insufficiency, Impaired Liver Function, Pulmonary Edema, New Headache/Vision Disturbance/RUQ pain.
Boring Rosen's Box Alert!!! These are 5 most common types of intracranial malignancy causing headache.
Metastatic: Breast, Lung, GI, Melanoma
Meningioma
Glioblastoma
Primary CNS lymphoma
Pituitary adenoma