Headache

Headache is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Pain in the cranium, orbits, or upper neck
  • Pain within the skull is projected to the surface:
    • Intracranial:
      • Arteries, veins, dura, meninges
    • Extracranial:
      • Skin, scalp, fascia, muscles
      • Mucosal linings of the sinuses
      • Arteries
      • Temporomandibular joints, teeth
  • Pain is transmitted via the V cranial nerve.
  • May be caused by a number of mechanisms:
    • Nerve irritation
    • Traction on pain-sensitive vessels
    • Vasodilatation of pain-sensitive vessels
      • Hypoxia, hypercapnia, fever, histamine injection, nitroglycerin ingestion
  • Complaint in 2–4% of all ED visits:
    • 95% have a benign etiology (lower in patients older than 50 yr)
    • Life-threatening etiologies are rare and can be difficult to diagnose.

Etiology

  • Migraine:
    • Intra/extracranial vasodilatation and constriction of pain-sensitive blood vessels
    • May also involve cortical depression
    • Throbbing headache
  • Tension:
    • Requires ≥10 attacks of a similar nature
    • Unknown etiology (possibly serotonin imbalance, decreased endorphins, spasm)
    • Most common type of recurring headache
    • Triggered by poor posture, stress, anxiety, depression, cervical osteoarthritis
    • Bilateral, nonpulsatile, band like
    • Mild to moderate intensity
    • 4–13 hr duration
  • Cluster headaches:
    • Triggered by alcohol, certain foods, altered sleep habits, strong emotions
    • May involve vasospasm near cranial nerves
  • Intracranial (traction, pressure):
    • Mass lesions
    • Idiopathic intracranial hypertension
  • Extracranial (compression):
    • Pathology causing pain in a peripheral nerve of the head and neck
  • Inflammation:
    • Temporal arteritis
    • Cerebral vasculitis
  • Thrombosis:
    • Cerebral venous sinus thrombosis (CVST)
  • Impaired vascular autoregulation/endothelial dysfunction:
    • Posterior reversible leukoencephalopathy syndrome (PRES)
    • Reversible cerebral vasoconstriction syndrome (RCVS)

Pediatric Considerations
Serious causes of headache in children are rare but those who come to the ED for this complaint should all have follow-up with a pediatrician.


Geriatric Considerations
Older patients with new headache have a higher likelihood of a serious etiology and should have more thorough evaluation with a low threshold for imaging.


Pregnancy Considerations
In addition to all other causes of headache, pregnant women (and recently postpartum women) are at increased risk for CVST, eclampsia, PRES, and RCVS.

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Basics

Description

  • Pain in the cranium, orbits, or upper neck
  • Pain within the skull is projected to the surface:
    • Intracranial:
      • Arteries, veins, dura, meninges
    • Extracranial:
      • Skin, scalp, fascia, muscles
      • Mucosal linings of the sinuses
      • Arteries
      • Temporomandibular joints, teeth
  • Pain is transmitted via the V cranial nerve.
  • May be caused by a number of mechanisms:
    • Nerve irritation
    • Traction on pain-sensitive vessels
    • Vasodilatation of pain-sensitive vessels
      • Hypoxia, hypercapnia, fever, histamine injection, nitroglycerin ingestion
  • Complaint in 2–4% of all ED visits:
    • 95% have a benign etiology (lower in patients older than 50 yr)
    • Life-threatening etiologies are rare and can be difficult to diagnose.

Etiology

  • Migraine:
    • Intra/extracranial vasodilatation and constriction of pain-sensitive blood vessels
    • May also involve cortical depression
    • Throbbing headache
  • Tension:
    • Requires ≥10 attacks of a similar nature
    • Unknown etiology (possibly serotonin imbalance, decreased endorphins, spasm)
    • Most common type of recurring headache
    • Triggered by poor posture, stress, anxiety, depression, cervical osteoarthritis
    • Bilateral, nonpulsatile, band like
    • Mild to moderate intensity
    • 4–13 hr duration
  • Cluster headaches:
    • Triggered by alcohol, certain foods, altered sleep habits, strong emotions
    • May involve vasospasm near cranial nerves
  • Intracranial (traction, pressure):
    • Mass lesions
    • Idiopathic intracranial hypertension
  • Extracranial (compression):
    • Pathology causing pain in a peripheral nerve of the head and neck
  • Inflammation:
    • Temporal arteritis
    • Cerebral vasculitis
  • Thrombosis:
    • Cerebral venous sinus thrombosis (CVST)
  • Impaired vascular autoregulation/endothelial dysfunction:
    • Posterior reversible leukoencephalopathy syndrome (PRES)
    • Reversible cerebral vasoconstriction syndrome (RCVS)

Pediatric Considerations
Serious causes of headache in children are rare but those who come to the ED for this complaint should all have follow-up with a pediatrician.


Geriatric Considerations
Older patients with new headache have a higher likelihood of a serious etiology and should have more thorough evaluation with a low threshold for imaging.


Pregnancy Considerations
In addition to all other causes of headache, pregnant women (and recently postpartum women) are at increased risk for CVST, eclampsia, PRES, and RCVS.

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