Cardinal Presentations
This post is part of a series called “Cardinal Presentations”, based on Rosen’s Emergency Medicine (8th edition).
Pathophysiology of Headache (“cephalalgia”)
- Sensation via meninges and blood vessels, mediated via CN V.
High-Risk Historical Features (indications for imaging)
- Sudden onset (seconds/minutes), patient recalls activity at onset
- Worst in life or change in character from established headache
- Fever, neck pain/stiffness
- Altered mental status
- Malignancy
- Coagulopathy: iatrogenic, hepatopathy, dialysis
- Immunocompromised
- Rare: CO exposure, jaw claudication, PCKD
Location of Pain
- Unilateral: migraine
- Periorbital: glaucoma, CVT, optic neuritis, cluster
- Facial/maxillary: trigeminal neuralgia, sinusitis
- Temporal: GCA
- Occipital: cerebellar stroke
- Nuchal: meningitis
Evaluation of Headache 2
Characteristics of Primary Headaches
| Type | Location | Duration | Quality | Associated symptoms | Comment |
|---|---|---|---|---|---|
| Migraine | Unilateral | Hours to days | Throbbing | Photophobia, phonophobia | Atypical migraines with neurological findings (basilar, ophthalmoplegic, ophthalmic, hemiplegic) |
| Tension | Bilateral | Minutes to days | Constricting | None | |
| Cluster | Unilateral, periorbital | Minutes to hours | Throbbing | Conjunctival injection, lacrimation, rhinorrhea, miosis, eyelid edema | Males 90%, triggered by EtOH. |
Physical Examination Findings
- Vital Signs
- Fever: present in 95% of patients with meningitis
- Head
- Trauma: signs of basilar skull fracture
- Temporal artery tenderness/induration: GCA
- Pericranial muscle tenderness: tension headache
- Trigger point, Tinnel sign: occipital neuralgia
- Eyes
- Pupillary defects: aneurysm with CN III compression
- Papilledema, absence of spontaneous venous pulsations: elevated intracranial pressure
- EOM abnormalities: ICH, mass lesion, neuropathy (DM, Lyme)
- Horner syndrome (ptosis, miosis, anhidrosis): carotid dissection
- Visual field defect: stroke, atypical migraine
- Conjunctival injection: glaucoma (fixed, mid-size pupil, elevated intraocular pressure), cluster headache
- Mouth
- Thrush: immunocompromise
- Sinuses
- Tenderness to palpation, abnormal transillumination: sinusitis
- Neck
- Resistance to supine neck flexion: meningitis
- Kernig: supine position, hip flexed, knee flexed, resistance to knee extension
- Brudzinski: supine position, neck flexion results in knee flexion
- Jolt accentuation: patient rotates head side-to-side, 2-3 times/sec exacerbates headache
CSF Analysis 4
| Test | Bacterial | Viral | Fungal/TB |
|---|---|---|---|
| Opening pressure | >15cm H20 | Normal | Normal |
| WBC (cells/mm3) | >1,000 | <100 | Variable |
| Differential | PMN | Lymphocytes | Lymphocytes |
| Protein (mg/dL) | >250 | >50 | >50 |
| Glucose (mg/dL) | <10 | Normal | <45 |
References:
- Russi, C. (2013). Headache. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 170-175). Elsevier Health Sciences.
- Godwin SA, Villa J. “Acute headache in the ED: Evidence-Based Evaluation and Treatment Options.” Emerg Med Pract 2001; 3(6): 1-32.
- Edlow, J. A., Panagos, P. D., Godwin, S. A., Thomas, T. L., & Decker, W. W. (2008). Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. Annals of emergency medicine, 52(4), 407–436. doi:10.1016/j.annemergmed.2008.07.001
- Seehusen, D. A., Reeves, M. M., & Fomin, D. A. (2003). Cerebrospinal fluid analysis. American family physician, 68(6), 1103–1108.
- WikEM: Headache