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Headache

Headache. Dr Sarah Robinson Consultant Emergency Medicine Southampton. Life-threatening Causes:. Subarachnoid haemorrhage Meningitis/ encephalitis Space Occupying Lesion Temporal Arteritis Pre-eclampsia. Other diagnoses to consider. Venous sinus thrombosis Dissection

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Headache

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  1. Headache Dr Sarah Robinson Consultant Emergency Medicine Southampton Headache

  2. Life-threatening Causes: • Subarachnoid haemorrhage • Meningitis/ encephalitis • Space Occupying Lesion • Temporal Arteritis • Pre-eclampsia Headache

  3. Other diagnoses to consider • Venous sinus thrombosis • Dissection • Hypertensive encephalopathy • Glaucoma/ iritis • CO poisoning Headache

  4. Diagnoses you will not make in the ED • Migraine • Coital cephalgia • Exertional headache Headache

  5. History • Site • Onset • Character • Radiation • Associated symptoms • Timing • Exacerbating/ relieving • Severity Headache

  6. Red flags: history • Thunder-clap headache • Worse headache ever • Syncopal episode • Altered mental state • Onset with exercise • Worse on waking • Seizure Headache

  7. Beware... • Elderly • Immunocompromised • Previous neurosurgery (shunts) Headache

  8. Red flags: signs • Fever • Altered mentation • Focal neurology • Meningism Headache

  9. Examination • Appearance • Photophobic • Rash • Temperature • BP • Kernigs/ Brudzinski • Focal neuro deficit • Visual fields • Fundoscopy Headache

  10. Subarachnoid haemorrhage • Up to 50% initially misdiagnosed • 15% re-bleed early • 40% re-bleed in next 4/52 • 1 in 10 ED Pts with thunderclap headache Headache

  11. SAH: aetiology • Family history • Smoking • Hypertension • Alcohol • Cocaine Headache

  12. SAH: history • Most thunderclap • Worse headache ever • Seizure at onset • Neck stiffness Headache

  13. SAH: signs • May be normal • Decreased GCS • III CN palsy • Retinal haemorrhages Headache

  14. Headache

  15. SAH: investigations • CT • 98% sensitive if within 12 hours • LP Headache

  16. SAH: Management in ED • ABCD defG • Analgesia • Anti-emetic • D/W senior • CT and refer Headache

  17. SAH: pitfalls • “not worse ever headache” • “Headache improved with cocodamol” • “CT was negative” Headache

  18. Meningitis • Headache • Fever • Neck stiffness • Altered mental state • Sepsis/ SIRS Headache

  19. Temporal arteritis • Older • Scalp tenderness • Jaw claudication • ESR Headache

  20. Summary • Thunderclap headache? • Senior review • Never diagnose migraine in ED Headache

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