CMN 568 - Exam 5
OTTAWA SAH Clinical Decision Rule:
-100% sensitivity in predicting subarachnoid hemorrhage; pt. seeking care in ED
c/o acute nontraumatic headache should be evaluated for SAH if they have one
or more of the following:
- 40yearsorolder
- Neckpain/stiffnes
- Witnessed LOC
- Onset during exertion
- Thunder clap headache(instantly peakingpain)
- Limited neck flexion(on exam)
Ipsilateral ptosis + miosis
Horner synfrom + HA = carotid artery dissection
Papilledema or absent retinal venous pulsations
Elevated ICP --> F/U with neuro imaging before LP
HA + HTN + retinal cotton wool spots, flame hemorrhages, and disc swelling
Acute severe hypertensive retinopathy
Older than 60 yrs old + HA
Examine for scalp or temporal artery tenderness
Fever + Acute HA
Meningeal inflamamtion (Kernig / Brudzinski sign); abssence of jolt accentuation
of HA cannot accurately rule out meningitis --> needs LP
Diagnostic imaging for Acute Headache
,Non-contrast CT of the head --> sufficient to exclude ICH + intracranial masses
(exceptions: lymphoma, toxoplasmosis in HIV+, herpes simplex encephalitis,
brain abscess)
5th most common reason for ED visits
Acute headache
Treatment for migraines
Acute:
NSAIDS (PO, nasal, IM toradol), metoclopramide, dihydroergotamine, triptants
(PO, nasal, SubQ)
PO 5-HT1F receptor agonist (Lasmiditan) --> currently in clinical trials
AVOID morphine / hydromorphone as 1st line therapy
Chronic / new daily persistent HA (unresponsive to other therapy):
Subanesthetic ketamine infusion
Treatment of headaches in the elderly
Peripheral nerve blocks
Non-pharmacologic treatment of migraine / cluster HA
Noninvasive vagus nerve stimulation
Treatment for refractory migraine + pregnancy
Peripheral nerve blocks
, 1st line treatment for cluster headaches
Sumatriptan: SQ, intranasal or inhaled (w/100% O2 via 12-15L/min
non-rebreather x 15 min)
Analgesic rebound headache
Ergotamines, triptans, medications containing butalbital, and opioids: lead to
medication overuse headache when taken more than 10 days per month
Acetaminophen, acetylsalicyclic acid, and NSAIDS: may also be offenders if
taken more than 15 days per month
Psudotumor cerebri
Idiopathic intracranial hypertension
Prophylactic medications for cluster headache
Lithium: titrate accordign to serum levels
Verapamil: routine ECG to monitor PR interval
Topiramate
Delay for these meds to take effect, use transitional therapy until effective -->
- Prednisone: 60mg x 5 days --> gradual withdrawal over 7-10 days. Effective in
70-80% of patients
- Ergotamine tartrate: rectal suppository, PO, SubQ injection
Posttraumatic headache treatment
Responds to simple analgesics
OTTAWA SAH Clinical Decision Rule:
-100% sensitivity in predicting subarachnoid hemorrhage; pt. seeking care in ED
c/o acute nontraumatic headache should be evaluated for SAH if they have one
or more of the following:
- 40yearsorolder
- Neckpain/stiffnes
- Witnessed LOC
- Onset during exertion
- Thunder clap headache(instantly peakingpain)
- Limited neck flexion(on exam)
Ipsilateral ptosis + miosis
Horner synfrom + HA = carotid artery dissection
Papilledema or absent retinal venous pulsations
Elevated ICP --> F/U with neuro imaging before LP
HA + HTN + retinal cotton wool spots, flame hemorrhages, and disc swelling
Acute severe hypertensive retinopathy
Older than 60 yrs old + HA
Examine for scalp or temporal artery tenderness
Fever + Acute HA
Meningeal inflamamtion (Kernig / Brudzinski sign); abssence of jolt accentuation
of HA cannot accurately rule out meningitis --> needs LP
Diagnostic imaging for Acute Headache
,Non-contrast CT of the head --> sufficient to exclude ICH + intracranial masses
(exceptions: lymphoma, toxoplasmosis in HIV+, herpes simplex encephalitis,
brain abscess)
5th most common reason for ED visits
Acute headache
Treatment for migraines
Acute:
NSAIDS (PO, nasal, IM toradol), metoclopramide, dihydroergotamine, triptants
(PO, nasal, SubQ)
PO 5-HT1F receptor agonist (Lasmiditan) --> currently in clinical trials
AVOID morphine / hydromorphone as 1st line therapy
Chronic / new daily persistent HA (unresponsive to other therapy):
Subanesthetic ketamine infusion
Treatment of headaches in the elderly
Peripheral nerve blocks
Non-pharmacologic treatment of migraine / cluster HA
Noninvasive vagus nerve stimulation
Treatment for refractory migraine + pregnancy
Peripheral nerve blocks
, 1st line treatment for cluster headaches
Sumatriptan: SQ, intranasal or inhaled (w/100% O2 via 12-15L/min
non-rebreather x 15 min)
Analgesic rebound headache
Ergotamines, triptans, medications containing butalbital, and opioids: lead to
medication overuse headache when taken more than 10 days per month
Acetaminophen, acetylsalicyclic acid, and NSAIDS: may also be offenders if
taken more than 15 days per month
Psudotumor cerebri
Idiopathic intracranial hypertension
Prophylactic medications for cluster headache
Lithium: titrate accordign to serum levels
Verapamil: routine ECG to monitor PR interval
Topiramate
Delay for these meds to take effect, use transitional therapy until effective -->
- Prednisone: 60mg x 5 days --> gradual withdrawal over 7-10 days. Effective in
70-80% of patients
- Ergotamine tartrate: rectal suppository, PO, SubQ injection
Posttraumatic headache treatment
Responds to simple analgesics
