Acute Headache in the Emergency Department

By Courtney Cassella, MD

Resident Physician, Icahn School of Medicine at Mount Sinai

Edited by Stephen Alerhand, MD and Alex Koyfman, MD

Clinical Case



A 56-year-old woman with a past medical history of hypertension and diabetes mellitus presents with a gradual onset, severe headache for the past 8 hours. The headache is described as the worst headache of her life, sharp, starts anteriorly and radiates to the back of the head/neck. The patient is nauseous but has not vomited. She denies fevers, chills, neck stiffness, vision changes, eye pain, numbness, or weakness.

Physical examination reveals an afebrile, mildly hypertensive, alert and oriented woman in severe distress secondary to pain. Otherwise, physical examination is unremarkable with no neurologic deficits.

Differential Diagnosis

Emergent

Subarachnoid or Intracerebral Hemorrhage

CNS infection: Meningitis, Encephalitis, Brain abscess

Carbon Monoxide Poisoning

Temporal Arteritis

Increased Intracranial Pressure: Mass, Idiopathic Intracranial Hypertension, Shunt Failure

Cerebral Sinus Thrombosis

Cervicocranial Artery Dissection

Subdural Hematoma

Acute Angle Closure Glaucoma

Non-emergent

Tension

Migraine

Cluster

Febrile headache

Dental, TMJ

Trigeminal Neuralgia

Post-Lumbar Puncture headache

General Approach to Evaluation 3, 6, 22, 23

History of Present Illness

Onset

— Sudden versus gradual onset

— Rest versus exertion (including cough, bowel movement, sexual activity)

Location

— Although this is not reliable for diagnosis, in a constellation of symptoms can point toward a specific type of headache.

Aggravators/Alleviators

— Worse with awakening/bending over (increased intracranial pressure)

— Comes and goes with specific enclosed settings (carbon monoxide)

— Others with similar headache in the household or place of work (carbon monoxide)

Associated symptoms

— Nausea, vomiting, photophobia (non-specific)

— Altered mental status, confusion

— Syncope

— Seizure

— Vision changes, eye pain (glaucoma)

— Jaw claudication (temporal arteritis)

— Numbness, weakness

Other History Points

— Prior headaches

— Prior neuroimaging

— Immunosuppression, Hypertension, Diabetes Mellitus, Malignancy, Coagulopathy

— Pregnant, postpartum

— Medications including nitroglycerin, analgesics, MAOIs, anticoagulants, birth control

— Alcohol, cigarette, or cocaine use

Family history

— Relatives with subarachnoid hemorrhage

— Migraine headaches

Physical exam

General

— Mental status, orientation

Vital Signs

— Hypertension

— Bradycardia

— Fever

HEENT

— Palpate temporal artery

— Palpate TMJ, mouth opening/closing

— Kernig or Brudzinski signs (not sensitive)

— Conjunctival injection, pupil reactivity, visual acuity, slit lamp exam, fundus examination for papilledema

Neurologic

— Cranial nerve examination – CN VI palsy (increased ICP)

— Strength, Sensation, Reflexes

— Finger to nose, Heel to shin, Rapid alternating movements, Pronator drift, Romberg

— Gait – ataxia

Clinical Features of Dangerous Headaches 3, 6, 24

Subarachnoid or Intracerebral Hemorrhage 2, 10

HA Quality: “Thunderclap headache”: sudden, severe, reaches maximal intensity within minutes, onset with exertion

Associated sx: nausea, vomiting, nuchal rigidity, altered mental status, syncope, seizure

Hx: recent severe headache (sentinel bleed), family history of SAH, hypertension, smoking, cocaine use, connective tissue disease (SAH), amyloid angiopathy (intracerebral)

Exam: change in mental status, neurologic deficits commonly cranial nerves, motor

CNS Infection 14-16

HA Quality: gradual, moderate to severe

Associated sx: fever, meningismus, altered mental status, seizures, rash, photophobia, psychiatric sx (encephalitis), cognitive deficits (encephalitis)

Hx: immunization status, recent outbreaks, local epidemics, sinusitis, otitis media, brain surgery, military barracks, dormatory

immunocompromised (HIV, AIDS, immunosuppressants) à think cryptococcal meningitis, toxoplasmosis

Exam: altered mental status, Kernig, Brudzinski, papilledema, skin exam, focal neurologic deficits

Carbon Monoxide Poisoning 8, 9, 17

HA Quality: gradual, intensity does not correlate with COhb levels, dull or throbbing, frontotemporal or diffuse, no pattern rules out or in carbon monoxide 10

Associated sx: dizziness, fatigue, weakness, nausea, vomiting, confusion, syncope, seizure, chest pain (rare), dyspnea (rare)

Hx: headache in the winter months, household or work contacts with headache, evidence of self harm, ask about suicidal intent

Exam: confused to comatose, ataxia (severe)

Temporal Arteritis 21, 25

HA Quality: gradual, severe, throbbing, unilateral frontotemporal

Associated sx: jaw claudication, vision changes/loss of vision, polymyalgia rheumatic, scalp tenderness

Hx: new onset or change in pattern of HA, HA with brushing hair, jaw pain after latency of tough chewing localized at the muscles

Exam: temporal artery tenderness, absent temporal artery pulsation, change in visual acuity

Criteria (3 of 5) 12

>50y

New-onset localized headache

Temporal artery tenderness or decreased pulse

ESR >50mm/H

Abnormal arterial biopsy findings

Increased ICP: tumor/mass, idiopathic intracranial hypertension (IIH), shunt failure 7, 13, 24

HA Quality: gradual, unilateral or bilateral

“Classic”: severe, early morning or nocturnal

Typical: moderate to severe, intermittent, nonspecific (aching, pressure, tightness, throbbing, shooting), progressive

IIH: lateralized, throbbing

Associated sx: nausea, vomiting, vision changes, neurologic deficits

Hx: HIV/AIDS à CNS lymphoma; malignancy à brain metastasis; history of shunt

IIH: young, female, obese

Exam: papilledema, neurologic deficits, CN VI palsy, skull-based metastases syndromes described by Greenberg et al 7

Cerebral Venous Thrombosis 20, 27

HA Quality: 1/3 acute, 1/3 sub-acute (<1mo), 1/3 chronic, diffuse

Associated sx: nausea, vomiting, seizures

Hx:

Hypercoagulable states: Oral contraceptive use, postpartum, post-operative, malignancy

Coagulation disorders: Factor V Leiden, Antithrombin III deficiency, Protein C or S deficiency, plasminogen deficiency, hyperhomocysteinemia

Polycythemia, sickle cell disease

Vasculitis – Behcet’s ,Wegener’s granulomatosis, sarcoidosis

Septic CVT – local (i.e. mastoiditis, otitis media, sinusitis, tonsillitis) or generalized (i.e. septicemia, endocarditis)

Exam: +/- papilledema, fluctuating neurologic deficits

Cavernous sinus – ocular nerve palsies, ipsilateral ocular affection (chemosis, proptosis, papilledema)

Lateral sinus – aphasia if left

Deep cerebral venous system – coma, motor deficits, aphasia

Cervicocranial Artery Dissection 18

HA Quality: sudden or gradual, severe, non-throbbing, occipital (vertebral), facial/frontotemporal pain (internal carotid)

Associated sx: nausea, vomiting, neck pain, vertigo

Hx: minor trauma within 6 hours of onset of head/neck pain

Exam:

Internal Carotid

Audible pulsatile tinnitus for the patient or bruit

Partial Horner syndrome – ptosis, meiosis without anhidrosis

Cranial nerve palsies, particularly lower (III – diplopia, V – facial numbness, VII – facial paresis, XII – tongue deviation)

Vertebral

Resemble lateral medullary syndrome

Upper extremity weakness

Subdural Hematoma 3

HA Quality: gradual, moderate to severe

Associated sx: nausea, vomiting, altered mental status

Hx: elderly, remote trauma, history of alcohol abuse, anticoagulation

Exam: change in mental status, neurologic deficits

Acute Angle Closure Glaucoma 1, 26

HA Quality: sudden, moderate to severe, centered about the eye

Associated sx: nausea, vomiting, blurred vision, foggy vision or halos

Hx: precipitated dilation, far sighted

Exam: mid-dilated, globe is hard, unreactive to light, reduced visual acuity, hyperemia more prominent adjacent to limbus, hazy cornea, tonometry >20mmHg