Lê Vĩnh Nghi, MD
Internal Medicine Resident
VinUniversity GME Program
Update on acute headache diagnosis in Emergency Department
The 24th National Scientific Congress of Vietnam Association of Critical Care Medicine, Emergency and Clinical Toxicology
Background
2
04/04/2024
Burch R. The Prevalence and Impact of Migraine and Severe Headache in the United States. Headache. 2018
Tabatabai RR. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes. 2016
Pathophysiology
3
04/04/2024
Osmosis: Headaches: Pathology review: Video & Anatomy
Gaul C. Pathophysiology of Headaches. Dtsch Med Wochenschr. 2017
The problem
ED doctors triage
Early assessing danger signs: important to prevent consequence
Response to analgesics: not reliable in DDx and exclusion
4
04/04/2024
International Classification of Headache Disorders (ICHD-3)
Tabatabai RR. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes. 2016
History taking & Physical examination
5
04/04/2024
Uptodate: Evaluation of the adult with nontraumatic headache in the emergency department
History taking |
First time / Sudden onset |
Worst headache |
No similar headache |
Change in pattern |
SOCRATES |
Past history Medications, toxin�Social history Family history |
Physical examination |
Level of consciousness |
Vital signs |
Neurologic abnormalities |
Meningismus |
Toxic appearance ? |
Vascular: Carotid bruit Eye: Vision, redness, pupil Sinus: Tenderness Dental: Infection |
The headache approach pathway
From Secondary causes to Primary causes
Tension-type
Migraine
Trigeminal autonomic
Other primary headache
6
04/04/2024
International Classification of Headache Disorders (ICHD-3)
Important cannot-miss secondary causes
7
04/04/2024
Chinthapalli K et al. Assessment of acute headache in adults - what the general physician needs to know. Clin Med (Lond). 2018
Tabatabai RR. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes. 2016
RED FLAGS – SNNOOP10
8
04/04/2024
Do TP et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019
M S, Lamont AC. Red flags in patients presenting with headache: clinical indications for neuroimaging. Br J Radiol. 2003
or > 50 years old
First disclaimer: Secondary headache
9
04/04/2024
New; Sudden; Progressive; Infection; ≥ 50 y.o
Neurologic sign; Cancer; Immunosuppression
→ Look for secondary headache
You are not wasting the money
Tabatabai RR. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes. 2016
Consider emergent neuroimaging
Other lab tests: CBC, CRP, LP
Check other organs too!
Second disclaimer: Primary headache
After excluding life-threatening 2nd causes
Consult; Treat primary headache; Discharge
10
04/04/2024
Tabatabai RR. Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes. 2016
ACEP 2019 Headache Guideline
Risk-stratification strategies: Ottawa SAH Rule (B)
SAH Imaging:
Normal noncontrast head CT + normal neurologic exam w/n 6 hrs can be used to rule out SAH (B)
If still at risk for SAH and normal CT, then LP or CTA (C)
11
04/04/2024
ACEP 2019: Critical Issues in the Evaluation and Management of Adult Patients
Presenting to the Emergency Department With Acute Headache
Case scenarios
Case scenario
CC: 51 y.o female, no PMH, presents to ED with acute headache
HPI: Started at 5 a.m. maximal after 30 minutes, occipital area, constant, VAS 10/10, associated with nausea
PE: A&O x 4, HR 80, BP 140/90, T 37, SpO2 96, distress because of headache, neck stiffness (+), no weakness or sensory deficits or other abnormalities
13
04/04/2024
Lê Vĩnh Nghi – 108 Military Central Hospital
Case scenario
14
04/04/2024
Lê Vĩnh Nghi – 108 Military Central Hospital
Subarachnoid hemorrhage
Take home messages
15
04/04/2024
Emergent imaging, lab tests for secondary causes
Maximize recognition – Minimize dangerous exclusion