Acute Headache Assessment and Neurological Emergencies Quiz

Acute Headache Assessment and Diagnosis

• A thorough clinical examination is crucial for excluding serious pathology in headache cases
• Investigations should only be requested when necessary, as imaging is not a substitute for a robust clinical assessment
• Patients often struggle to describe their headaches beyond intensity and location, requiring clinicians to draw out relevant features during history-taking
• Onset and evolution of symptoms are critical focuses during headache assessment
• Thunderclap headache, reaching maximum intensity within 60 seconds, necessitates a brain CT scan and lumbar puncture to rule out subarachnoid hemorrhage
• Medication overuse headache should be considered for individuals frequently using analgesia for a primary headache disorder
• Bacterial meningitis typically presents with fever, neck stiffness, altered mental status, and headache
• Fewer than 1 in 1,000 people under 50 years old presenting with an isolated headache will have a brain tumor
• Primary headaches, especially migraines, are common in the acute setting and require positive diagnosis and treatment
• Neurological examination should particularly assess vital sign disturbance, meningism, altered consciousness, and focal neurological deficit
• Useful questions during history-taking include inquiring about headache frequency before the current episode, duration, triggers, and associated symptoms
• Ocular examination for ophthalmoplegia, ptosis, and pupillary abnormalities is crucial during headache assessment

Neurological Emergencies and Headaches: Key Points

• Acute bacterial meningitis typically presents with a headache in 87% of cases, with the classic triad of neck stiffness, fever, and altered mental status occurring in only 44% of cases.
• Multi-slice helical CT imaging within 6 hours may miss up to 20% of cases of meningitis, necessitating a lumbar puncture (LP) for spectrophotometric assessment of xanthochromia if the scan is negative.
• Following diagnosis of meningitis, CT or magnetic resonance angiography is performed, and if no aneurysm is found despite subarachnoid hemorrhage (SAH), catheter angiography remains the gold standard.
• Thunderclap headaches may be due to other vascular headaches, carotid artery dissection, vertebrobasilar dissection, or reversible cerebral vasoconstriction syndrome (RCVS), among others.
• Giant cell arteritis (GCA) should be considered in adults >50 years with new chronic headache, especially if there is systemic malaise, and necessitates a full blood count, ESR, and CRP.
• Carbon monoxide toxicity may cause non-specific headache, dizziness, nausea, and confusion, and requires a high index of suspicion for diagnosis.
• Acute angle-closure glaucoma may present as frontal headache with nausea and visual phenomena, often misdiagnosed as migraine, and requires intraocular pressure measurement for diagnosis.
• Headaches are common in adults with malignant brain tumors, occurring in >50% of cases, but are the sole presenting symptom in just 2% of cases.
• Indications for neuroimaging before lumbar puncture in suspected bacterial meningitis include focal neurologic signs, presence of papilloedema, continuous or uncontrolled seizures, GCS < 15, age >40 years, thunderclap headache, headache onset during exertion, neck pain or stiffness, witnessed loss of consciousness, and limited neck flexion on examination.
• Most patients with chronic headache also have seizures, focal neurologic deficits, or altered mental status, with headache characteristics varying but often manifesting raised pressure features.
• Fundoscopy to exclude papilloedema is mandatory in all chronic headache patients, particularly in obese, young women with raised intracranial pressure and papilloedema with normal imaging, to consider idiopathic intracranial hypertension.
• Migraine is one of the top 10 causes of disability worldwide, characterized by photophobia, phonophobia, osmophobia, motion intolerance, moderate to severe throbbing pain, and nausea and/or vomiting.