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Headache Patient Management and Diagnosis: A Comprehensive Case Evaluation

Evaluate your performance in managing a headache patient. Examine diagnosis, intractable headaches, intracranial hemorrhage, and hypercoagulable states. Learn about pain management techniques, high-risk factors, and the role of MRI in detecting hyperacute bleeding. Explore the use of a coma cocktail and neuroprotective sedation in head injury cases.

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Headache Patient Management and Diagnosis: A Comprehensive Case Evaluation

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Presentation Transcript

  1. Case Evaluation • How do you think you did? • What do you think you did well? • What would you have done differently? • How do you think your colleagues did?

  2. Diagnosis? • Intractable Headache • Intracranial hemorrhage • Hypercoagulable state

  3. General Assessment of the Headache Patient • Mental status • Full neurologic examination • Cranial Nerves • Motor control • Sensory control • Reflexes • Cerebellar examination • Head to Toe Examination

  4. Management of Pain in Headaches • Narcotics • Compazine (studied in migraines) • Toradol / Ketoralac (NSAID) • Triptans

  5. High Risk Headaches • Trauma • Anticoagulation • Intracranial lesions • Hypertension • Pregnancy (Eclampsia) • Microvascular disease • Neurologic deficit

  6. MRI for Hyperacute Bleeding • Field Strength is Important • < 1.5 Teslas not good for detection • Newer machines 1.5 to 3 Teslas • Advanced Sequences better at detection • FLAIR (Fluid attenuated inversion recovery) • PD (Proton density) • GRE (gradient echo)

  7. MRI for Hyperacute: Studies • Three small studies have been performed • All less than 20 patients • Machines varied (1.5 to 3.0 teslas) • Detection rate was high • However two studies missed at least 1 patient • One study missed most patients on T1 and T2 • FLAIR appears to be the most specific

  8. Coma Cocktail • Do the DON’T D – Dextrose O – Oxygen N – Narcan T – Thiamine

  9. Neuroprotective Sedation • Concept – Intubation can increase risk of bleeding and worsen outcomes in head injury and bleed patients • Data - Limited

  10. Neuroprotective Medications • Lidocaine 1.5mg/kg bolus • Fentanyl 2mcg/kg bolus • Vecuronium • Defasiculation dose 0.01mg/kg • Paralyzing dose 0.1mg/kg • Etomidate 0.3mg/kg • Succinylcholine 1.5mg/kg

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