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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Environ 15 % de la population a présenté au moins une cépha- lée intense au cours des 3 derniers mois [1]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Cela explique que les céphalées constituent près de 1 % de l’ensemble des consultations ambulatoires [2] et environ 2 % des motifs de consultation aux urgences [3,4]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Bien qu’environ 95 % de ces patients rentrent à leur domicile avec un diagnostic de céphalée primaire, bénigne, le médecin de premier recours doit pouvoir détecter et référer une céphalée secondaire et potentiellement grave [3,4].
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Nous rappelons en préambule que l’intensité d’une céphalée n’est pas corrélée à sa gravité. La majorité des céphalées, même vues dans un contexte d’urgence, est constituée par les céphalées primaires
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Les céphalées de début brutal et/ou inhabituelles doivent être considérées comme des céphalées secondaires jusqu’à preuve du contraire et justifient la réalisation d’examens complémentaires en urgence
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Une céphalée que le patient reconnaît comme habituelle mais dont l’intensité est plus forte que d’habitude ou qui ne cède pas à la prise du traitement antalgique habituel, correspond la plupart du temps à une céphalée primaire réfractaire au traitement habituel. Dans ce cas, les exa- mens complémentaires sont inutiles et la prise en charge doit se concentrer sur l’obtention d’une antalgie, à condi- tion que l’examen physique, notamment neurologique, soit normal
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
En pratique, les céphalées vues en urgence peuvent être divisées en quatre grands tableaux cliniques (Fig. 1) : • céphalées brutales récentes ; • céphalées progressives récentes ; • céphalées paroxystiques récurrentes ; • céphalées chroniques quotidiennes. Chacun de ces 4 tableaux cliniques regroupe de nom- breuses étiologies, mais va cependant permettre d’orienter la prise en charge pour rechercher les causes principales de ces symptômes
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
• Quand a débuté la douleur ? (caractère récent) • En combien de temps la douleur a-t-elle été maximale ? (caractère brutal) • Avez-vous déjà présenté le même type de douleur ? (caractère inhabituel) • Que faisiez-vous quand la douleur a débuté (effort, . . .) ? • Existe-t-il des symptômes associés : fièvre, photo ou phonophobie, vomissements, cervicalgie, déficit neurologique focal, ralentissement psycho-moteur, douleurs des ceintures ?
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
• Existe-t-il un contexte particulier : prise d’un nouveau médicament, prise de toxiques, exposition au monoxyde de carbone ; traumatisme ; grossesse ou post-partum, cancer, maladies systémiques (dont VIH) ; un geste avec effraction durale ou risque d’effraction a-t-il été réalisé dans le mois précédent (ponction lombaire, péri-durale, infiltration de nerfs rachidiens) . . .. ? • Existe-t-il un caractère positionnel (céphalées soulagées ou aggravées en décubitus) ?
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Si le médecin est auprès du patient, il faut rechercher de manière systématique (Accord professionnel) : • un trouble de la vigilance ; • de la fièvre ; • une hypertension artérielle ; • un syndrome méningé ; • un déficit neurologique focal (déficit moteur ou sensitif, diplopie, anomalie pupillaire, syndrome cérébelleux) ; • une pathologie de l’œil, des sinus, de l’oreille ou de la cavité buccale pouvant expliquer les céphalées
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Dans l’idéal, le patient sera adressé vers un hôpital disposant d’un service de neurologie (Accord professionnel). Ainsi, il est recommandé de prendre en charge EN URGENCE tout patient qui présente : • Une céphalée brutale voire en coup de tonnerre (intensité maximale en moins d’une minute), • Une céphalée récente ou d’aggravation récente (< 7 jours) et inhabituelle, • Une céphalée associée à une fièvre (en l’absence d’une cause générale évidente telle qu’un syndrome grippal en période épidémique), • Une céphalée associée à des signes neurologiques, • Une céphalée faisant évoquer une intoxication (notamment au CO), • Une céphalée dans un contexte d’immunodépression.
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
En cas de contact téléphonique, il est recommandé de conseiller au patient une consultation rapide (médecin traitant ou médecin de garde) dans les situations sui- vantes : • céphalée connue par le patient, mais ne cédant pas à la prise du traitement antalgique habituel ; • céphalée semi-récente (entre 8 jours et 6 mois) sans signe d’aggravation durant les derniers jours ; • céphalée ancienne (> 6 mois) dont la fréquence ou l’intensité sont difficiles à gérer par le patient
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
L’interrogatoire doit également permettre de préciser le profil évolutif de la céphalée : « Avez-vous une céphalée quotidienne et permanente ou avez-vous des crises ? ».
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Si le patient présente des crises, leur description (durée, localisation, intensité, signes associés, facteurs déclen- chant, nombre de jours de céphalées par mois, traitements déjà utilisés et efficacité) permet le diagnostic du type de céphalée. Un sujet peut avoir plusieurs types de céphalées primaires (par exemple, migraine sans aura et céphalée de tension)
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Si le patient a une céphalée chronique quotidienne, la description des céphalées oriente le diagnostic. Cependant, toute modification récente d’une céphalée primaire doit faire suspecter et écarter une céphalée secondaire. Par ailleurs, il faut rechercher soigneusement une prise exces- sive de traitements antalgiques (abus médicamenteux). Dans tous les cas, une céphalée chronique quotidienne (CCQ) existant depuis moins de six mois devra être explorée (Accord professionnel) [6]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Au cours des céphalées primaires, les explorations complémentaires sont inutiles lorsque les crises sont anciennes, reconnues comme habituelles par le patient, et satisfont tous les critères diagnostiques [5].
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
En dehors des crises, l’examen clinique général et neurologique est normal dans les céphalées primaires (hormis un signe de Claude-Bernard Horner parfois présent en inter-critique dans le cadre de l’algie vasculaire de la face)
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[unknown IMAGE 7090677353740]
[NEURO - CEPHALEE] - Recommandation prise en charge céphalée aux urgences 2018
#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU #has-images
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Devant toute première crise d’AVF, une IRM encéphalique et une angiogra- phie cérébrale et cervicale par ARM ou angioscanner doivent être faites (Accord professionnel) [7].
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
État de mal migraineux Il correspond, chez un migraineux connu, à la persistance d’une crise invalidante pendant plus de 72 heures. Des périodes de soulagement de moins de 12 heures (suite à la prise de traitement ou lors du sommeil) peuvent exister. Cette entité est rare [8]. Il convient d’éliminer une céphalée secondaire avant de retenir ce diagnostic
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Céphalées chroniques quotidiennes (CCQ) Les CCQ surviennent chez un patient présentant anté- rieurement une céphalée primaire sous-jacente [6]. Elles peuvent être secondaires à un abus médicamenteux, défi- nit par au moins 15 jours par mois depuis au moins trois mois pour une prise d’antalgiques non opioïdes (paracéta- mol, aspirine, AINS), ou 10 jours par mois pour une prise d’opioïdes, d’ergotés de triptans et/ou en cas d’utilisation combinée de plusieurs médicaments par le patient [5]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Tout patient ayant présenté une céphalée répondant à l’un des critères de la règle d’Ottawa (Encadré 1 ) doit être pris en charge comme une suspicion d’hémorragie sous-arachnoïdienne (HSA) jusqu’à preuve du contraire (Grade B) (Perry et al., 2013).
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Règle d’Ottawa. La présence de l’un des 6 critères justifie la réalisation d’explorations à la recherche d’une HSA. Cette règle s’applique aux patients de plus de 15 ans présentant une céphalée sévère, non traumatique, ayant atteint son intensité maximale en moins d’une heure. Ne pas appliquer en cas de déficit neurologique, d’antécédent d’anévrisme, d’HSA, de tumeur cérébrale ou de céphalées récurrentes (≥ 3 en ≥ 6 mois). • Âge ≥ 40 ans. • Douleur ou raideur nucale. • Perte de connaissance constatée par un témoin. • Début durant un effort physique. • Céphalée en coup de tonnerre (Intensité > 7/10 en moins d’une minute). • Limitation de la flexion nucale.
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Un tiers des HSA se présente par une céphalée isolée [9].
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Règle d'Ottawa
#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Cependant, il peut être justifié d’explorer en urgence certaines céphalées ne répondant à aucun des critères de cette règle
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Le diagnostic positif d’HSA est affirmé par un scanner cérébral sans injection de produit de contraste qui a une sensibilité au maximum de 98 % lorsqu’il est réalisé dans les 12 premières heures après le début des symptômes (chutant à 93 % après 24 heures, 85 % à 5 jours et 50 % à 7 jours) (Grade B) [5,13,14].
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Suspicion HSA
#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Bien qu’un scanner sans injection soit indis- pensable, il n’est pas suffisant. Le Guide du bon usage des examens d’imagerie médicale édité par la Société Franc¸aise de Radiologie et la Société Franc¸aise de Médecine Nucléaire sous l’égide de la Haute Autorité de Santé et de l’Autorité de sûreté nucléaire (gbu.radiologie.fr) recommande la réa- lisation d’un angioscanner cérébral qui doit être associé de manière systématique si aucune hémorragie n’est visualisée spontanément, afin d’explorer le réseau artériel et le réseau veineux (Accord professionnel) [15,16]. L’angioscanner des troncs supra-aortiques doit être réalisé pour toute suspi- cion d’atteinte des artères cervicales (cervicalgie, signe de Claude-Bernard Horner, . . .) (Accord professionnel). Une IRM + ARM peut être réalisée en première intention si l’état clinique du patient le permet et si cela ne retarde pas la prise en charge (Accord professionnel) [16]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Devant une suspicion d’HSA, si l’imagerie ne permet pas d’obtenir un diagnostic, la ponction lombaire doit être réa- lisée de manière systématique, même si les céphalées ont disparu (Grade B) [13,14,17]. La xanthochromie est présente dans 100 % des cas d’HSA anévrismales lorsque le LCS est pré- levé entre 12 heures et 14 jours du début des symptômes et analysé en spectrophotométrie [5,13,18,19]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Devant une suspicion d’HSA, si l’angioscanner (ou IRM + ARM) ne permet pas d’obtenir un diagnostic, la ponction lombaire doit être réalisée de manière systématique, même si les céphalées ont disparu (Grade B) (Edlow et al., 2008 ; Steiner et al., 2013 ; Stewart et al., 2014). Il est recommandé de réaliser la ponction lombaire avec une aiguille atraumatique fine (25 gauge) afin de limiter le risque de céphalées post PL et les surcoûts qui seraient alors induits (Grade B) [25,26,27,28]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Devant un tableau de céphalée en coup de tonnerre, et en particulier en l’absence de malformation vascu- laire, il faudra évoquer et rechercher un syndrome de vasoconstriction cérébrale réversible (SVCR) [29] (Accord professionnel)
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Le SVCR est attribué à une anomalie transitoire et réversible de la régulation du tonus artériel cérébral, qui entraîne une vasoconstriction et une vasodilatation multifocale et diffuse. Elle est favorisée par la prise de substances vasoactives telles que le cannabis, la cocaïne, l’ecstasy, les amphétamines, le LSD, les antidépresseurs (inhibiteurs de recapture de la sérotonine ou sérotonine et noradrénaline), les décongestionnants nasaux, les trip- tans et les dérivés de l’ergot de seigle.
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Le début est brutal, typiquement avec des céphalées en coup de tonnerre récur- rentes, souvent déclenchées par l’activité sexuelle ou les manœuvres de Valsalva. Le SVCR peut se compliquer ou être associé à une hémorragie, une ischémie ou une dis- section d’artère cérébrale [31]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Le diagnostic nécessite la démonstration des anomalies artérielles typiques en ima- gerie par angioscanner ou angio IRM.
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SVCR
#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
La première imagerie peut-être normale lorsqu’elle est faite précocement dans les 4—5 premiers jours après les premiers symptômes, les anomalies étant maximales 2 à 3 semaines après les premiers symptômes
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[unknown IMAGE 7090712481036]
[NEURO - CEPHALEE] - Recommandation prise en charge céphalée aux urgences 2018
#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU #has-images
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Une dissection artérielle cervicale, une thrombose vei- neuse cérébrale, un SVCR ou une apoplexie pituitaire peuvent également se présenter comme une céphalée en coup de tonnerre avec un examen physique, un scanner et un LCS normaux
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
S’il existe une HSA, la recherche d’un anévrisme causal doit être réalisée. En première intention, on privilégiera un angioscanner ou une angio-IRM cérébrale (Accord professionnel). L’artériographie pourra être discutée au cas par cas.
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Céphalée inhabituelle à début progressif (présente ou aggravée depuis moins de 7 jours) L’interrogatoire et l’examen physique (avec fond d’œil) permettront de rechercher des signes d’hypertension intra- crânienne (céphalées plus intenses le matin au réveil, vomissements, flou visuel, éclipses visuelles, œdème papil- laire au fond d’œil) qui font évoquer un processus expansif intracrânien ou des cervicalgies qui font évoquer une dis- section des artères cervicales.
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Face à une céphalée inhabituelle présente ou aggravée depuis moins de 7 jours, une imagerie cérébrale doit être réalisée dans un délai rapide à la recherche d’un processus expansif intracrânien ou d’une cause vasculaire (Accord professionnel)
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Dans l’idéal, une IRM encéphalique avec séquences T1, T2, FLAIR et T1 injectée à la recherche de prises de contraste et de signes de thrombose veineuse sera réali- sée. Une séquence T2* pourra également être demandée afin de repérer un éventuel saignement et contribue à la recherche d’une thrombose veineuse. L’exploration des troncs supra-aortiques à la recherche d’une dissection jus- tifie la réalisation d’une séquence fat-sat (saturation de graisse), mais aussi d’une ARMTSA (Accord professionnel).
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Si l’imagerie n’apporte pas d’élément diagnostic, une ponction lombaire devra être discutée à la recherche d’une méningite ou d’un trouble de la pression du LCS (Accord professionnel). Cette PL ne devra pas être faite en cas de suspicion d’hypotension intracrânienne spon- tanée (tableau marqué par une céphalée orthostatique). Dans ce cas, l’IRM cérébrale avec injection devra être privilégiée
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Quand une hypotension intracrânienne est évo- quée, l’IRM doit être réalisée avant toute ponction lombaire (Accord professionnel)
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Devant une suspicion d’HTIC et en cas d’imagerie n’apportant pas de diagnostic, une analyse du LCS doit être réalisée (Accord professionnel). La mesure de pression sera réalisée en milieu spécialisé. Un examen du fond d’œil sera également réalisé.
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Le dosage des D-Dimères n’est pas recommandé pour exclure le diagnostic de thrombose veineuse cérébrale, envi- ron 20 % des patients avec des thromboses responsables de céphalées isolées présentant un dosage dans la norme (Grade B) [37,38] (Fig. 2).
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
On rappellera simplement que le traitement du SVCR est basé sur l’administration de nimodipine qui empiriquement est donnée aux mêmes doses que dans l’HSA, en association avec un traitement symptomatique de la céphalée (Accord professionnel). Tous les traitements ayant un effet vaso- constricteur doivent être stoppés.
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
D’autre part, la réponse au traitement antalgique ne présume pas d’une cause pri- maire et ne doit pas rassurer à tort [17,39]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Migraine Pour le traitement de la crise, on conseillera le repos dans une pièce sombre et calme (Accord professionnel). Il est également important de favoriser la réhydratation par voie orale ou par voie intraveineuse (Accord profes- sionnel). Au niveau médicamenteux, le traitement sera adapté aux thérapeutiques déjà rec¸ues par le patient. On utilisera en première intention un AINS par voie orale (Diclofenac 50 à 100 mg, Ibuprofène 400 mg, Kétopro- fène100 à 150 mg, Naproxène 500 mg), ou l’association Aspirine 900 mg + Métoclopramide 10 g (Grade A) [40—43]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Pour les AINS, l’ibuprofène et le kétoprofène ont une AMM pour la migraine en France. Il est recommandé d’utiliser une dose de 400 mg pour l’ibuprofène et de 100 à 150 mg pour le kétoprofène. En cas de contre-indication aux AINS, la prise d’un gramme de paracétamol associé à 10 mg de métoclopramide peut être une bonne alternative (Grade A) [44].
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Si le patient a déjà pris un AINS (ou paracéta- mol + métoclopramide) à bonne dose et ce sans efficacité, il est licite de proposer une prise de triptan (Grade A) [42,45,46]. Pour toute crise réfractaire au traitement de première ligne, on associera de manière systématique du métoclopramide en IV lente (10 mg sur 15 minutes), à visée anti-émétique si le patient présente des nausées mais également pour son effet anti-migraineux propre [47,48] (Grade A)
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Le métoclopramide étant un antagoniste dopa- minergique, il pourra être associé à un anti-cholinergique pour éviter les effets extra-pyramidaux, en particulier l’akathisie (Grade C). L’administration lente diminue le risque d’akathisie [49,50] [Grade B].
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[NEURO - CEPHALEE] - Recommandation prise en charge céphalée aux urgences 2018
#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU #has-images
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Si le patient a débuté par une prise de triptan, le traite- ment de recours peut être un AINS (Accord professionnel). En cas de nausées ou de vomissements rendant la voie orale impossible, un AINS (kétoprofene 100 mg, Aspirine 1000 mg) peut être administré par injection IV et le métoclopramide par voie IV [48,51—54] (Grade B). Pour les triptans, seul le sumatriptan dispose d’une forme en spray nasal. En dernier recours, si le spray nasal n’est pas toléré, la forme injectable SC du sumatriptan peut être envisagée (Grade A) [55]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Une perfusion IV de 25 mg d’amitriptyline en 2 heures peut être proposée en cas de persistance de la migraine malgré l’utilisation préalable detriptans et d’AINS (Accord professionnel). La dexaméthasone 10 mg en IV peut être utilisée, malgré une efficacité modérée [56] (Grade A)
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Migraine
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En dernier recours, une phénothiazine peut être utili- sée. La prochlorpérazine a le meilleur niveau de preuve, mais cette dernière n’est pas disponible en France [57]. À défaut, une perfusion IV lente de 0,1 mg/kg de chlorproma- zine (Largactil ® ) peut être proposée [58] (Grade A). L’effet sédatif est majeur et le patient doit en être prévenu. Mal- gré un bon niveau de preuve, les effets indésirables aigus et chroniques de ce traitement ne sont pas négligeables et le recours à cette thérapeutique doit être strictement limité (Accord professionnel)
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Migraine
#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Il n’est pas recommandé d’utiliser du magnésium en IV (Grade A) [59]. Il est également recommandé de ne pas utiliser d’opioïdes (Grade C) [29,60,61]
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
État de mal migraineux Il n’existe pas de traitement codifié pour cette entité rare qui est un diagnostic d’exclusion. Le transfert vers un service d’accueil des urgences est justifié pour effectuer un traite- ment intraveineux
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Céphalées de tension Le traitement reposera en première intention sur la prise d’un antalgique simple (Paracétamol 1 g) ou d’un AINS (Ibu- profène 400 mg ou Kétoprofène100 mg) [62,63] (Grade A). Là encore, l’adjonction de métoclopramide pour son effet antalgique est possible en respectant les précautions habi- tuelles, en cas de crises réfractaires [64] (Grade A). En dernier recours, une perfusion d’amitriptyline 25 mg peut être proposée (Accord professionnel).
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#Cephalee #Emergency #Guideline #Headache #Recommandation #SAU
Algie vasculaire de la face Deux traitements de crise ont une AMM et sont recommandés en première intention [7] : • le sumatriptan SC 6 mg (Grade A) ; • l’oxygène à un débit de 12 à 15 L/min, au masque à haute concentration pendant 15 à 20 minutes (Accord profes- sionnel)
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#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Patients with headache unrelated to trauma constitute approximately 2 percent of emergency department (ED) visits, though some studies suggest a rate as high as 4 percent [1-3].
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opics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2022. | This topic last updated: Sep 13, 2021. INTRODUCTION — <span>Patients with headache unrelated to trauma constitute approximately 2 percent of emergency department (ED) visits, though some studies suggest a rate as high as 4 percent [1-3]. The differentiation of the small number of patients with life-threatening headaches from the overwhelming majority with benign primary headaches (ie, migraine, tension, or cluster) is a




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
This topic will discuss how to approach adults presenting to the ED with headache, with an emphasis on those components of the history and physical examination that characterize high-risk headaches. Diagnostic tables to help guide this evaluation are provided (table 1 and table 2).
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essment of the headache patient; they help the clinician to determine whether the patient is at significant risk for a dangerous cause of their symptoms and what additional workup is necessary. <span>This topic will discuss how to approach adults presenting to the ED with headache, with an emphasis on those components of the history and physical examination that characterize high-risk headaches. Diagnostic tables to help guide this evaluation are provided (table 1 and table 2). (Related Pathway(s): Headache: Initial evaluation of adults in the emergency department.) Discussions of headache following trauma and other specific causes of headache are found separa




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
While some dangerous causes of headache may present with a gradual increase in pain, any severe, persistent headache that reaches maximal intensity within a few seconds or minutes after the onset of pain warrants aggressive investigation [6-8]
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the emergency department.) High-risk historical features — The following historical features are warning signs to the presence of a secondary headache (table 1) [4,5]: ●Sudden-onset headache – <span>While some dangerous causes of headache may present with a gradual increase in pain, any severe, persistent headache that reaches maximal intensity within a few seconds or minutes after the onset of pain warrants aggressive investigation [6-8]. Subarachnoid hemorrhage (SAH), for example, often presents with the abrupt onset of excruciating pain. Other serious etiologies of sudden-onset headache include reversible cerebral vas




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Subarachnoid hemorrhage (SAH), for example, often presents with the abrupt onset of excruciating pain. Other serious etiologies of sudden-onset headache include reversible cerebral vasoconstriction syndromes, carotid and vertebral artery dissections, venous sinus thrombosis, pituitary apoplexy, acute angle-closure glaucoma, unruptured cerebral aneurysms, colloid cyst of the third ventricle, and hypertensive emergencies ( table 3).
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with a gradual increase in pain, any severe, persistent headache that reaches maximal intensity within a few seconds or minutes after the onset of pain warrants aggressive investigation [6-8]. <span>Subarachnoid hemorrhage (SAH), for example, often presents with the abrupt onset of excruciating pain. Other serious etiologies of sudden-onset headache include reversible cerebral vasoconstriction syndromes, carotid and vertebral artery dissections, venous sinus thrombosis, pituitary apoplexy, acute angle-closure glaucoma, unruptured cerebral aneurysms, colloid cyst of the third ventricle, and hypertensive emergencies (table 3). In contrast, migraine headaches generally begin with mild to moderate pain and then gradually increase to a maximal level over one to two hours. (See "Overview of thunderclap headache".




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
In contrast, migraine headaches generally begin with mild to moderate pain and then gradually increase to a maximal level over one to two hours.
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ssections, venous sinus thrombosis, pituitary apoplexy, acute angle-closure glaucoma, unruptured cerebral aneurysms, colloid cyst of the third ventricle, and hypertensive emergencies (table 3). <span>In contrast, migraine headaches generally begin with mild to moderate pain and then gradually increase to a maximal level over one to two hours. (See "Overview of thunderclap headache".) Cluster headache may sometimes be confused with a serious headache since the pain from a cluster headache can reach full intensity within minut




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Cluster headache may sometimes be confused with a serious headache since the pain from a cluster headache can reach full intensity within minutes. However, cluster headache is transient (usually lasting less than one to two hours) and is associated with characteristic ipsilateral autonomic signs, such as tearing, miosis, or rhinorrhea.
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le 3). In contrast, migraine headaches generally begin with mild to moderate pain and then gradually increase to a maximal level over one to two hours. (See "Overview of thunderclap headache".) <span>Cluster headache may sometimes be confused with a serious headache since the pain from a cluster headache can reach full intensity within minutes. However, cluster headache is transient (usually lasting less than one to two hours) and is associated with characteristic ipsilateral autonomic signs, such as tearing, miosis, or rhinorrhea. (See "Cluster headache: Epidemiology, clinical features, and diagnosis".) Of note, many dangerous causes of headache can present with gradual-onset headache, including herpetic or Lyme




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Of note, many dangerous causes of headache can present with gradual-onset headache, including herpetic or Lyme meningitis, brain tumor, brain abscess, hypertensive encephalopathy, posterior reversible encephalopathy syndrome (PRES), and idiopathic intracranial hypertension.
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o two hours) and is associated with characteristic ipsilateral autonomic signs, such as tearing, miosis, or rhinorrhea. (See "Cluster headache: Epidemiology, clinical features, and diagnosis".) <span>Of note, many dangerous causes of headache can present with gradual-onset headache, including herpetic or Lyme meningitis, brain tumor, brain abscess, hypertensive encephalopathy, posterior reversible encephalopathy syndrome (PRES), and idiopathic intracranial hypertension. Furthermore, dangerous causes may present with atypical timing, and symptoms may overlap. As examples, most patients with cervico-cranial artery dissections and venous sinus thrombosis




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Furthermore, dangerous causes may present with atypical timing, and symptoms may overlap. As examples, most patients with cervico-cranial artery dissections and venous sinus thrombosis present with gradual-onset headaches, and some patients with acute-angle closure glaucoma develop headaches that simulate migraine and can be intermittent [ 9]
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e, including herpetic or Lyme meningitis, brain tumor, brain abscess, hypertensive encephalopathy, posterior reversible encephalopathy syndrome (PRES), and idiopathic intracranial hypertension. <span>Furthermore, dangerous causes may present with atypical timing, and symptoms may overlap. As examples, most patients with cervico-cranial artery dissections and venous sinus thrombosis present with gradual-onset headaches, and some patients with acute-angle closure glaucoma develop headaches that simulate migraine and can be intermittent [9]. (See "Aseptic meningitis in adults" and "Cerebral venous thrombosis: Etiology, clinical features, and diagnosis" and "Pathogenesis, clinical manifestations, and diagnosis of brain absc




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
The absence of similar headaches in the past is another finding that suggests a serious disorder. The "first" and "worst headache of my life" are descriptions that sometimes accompanies an intracranial hemorrhage or central nervous system (CNS) infection.
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" and "Reversible posterior leukoencephalopathy syndrome" and "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis".) ●No similar headaches in the past – <span>The absence of similar headaches in the past is another finding that suggests a serious disorder. The "first" and "worst headache of my life" are descriptions that sometimes accompanies an intracranial hemorrhage or central nervous system (CNS) infection. A new or unusual headache in a patient with acquired immunodeficiency syndrome (AIDS) or cancer is particularly worrisome, as it suggests an intracranial lesion or infection [10]. On th




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
A new or unusual headache in a patient with acquired immunodeficiency syndrome (AIDS) or cancer is particularly worrisome, as it suggests an intracranial lesion or infection [ 10].
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g that suggests a serious disorder. The "first" and "worst headache of my life" are descriptions that sometimes accompanies an intracranial hemorrhage or central nervous system (CNS) infection. <span>A new or unusual headache in a patient with acquired immunodeficiency syndrome (AIDS) or cancer is particularly worrisome, as it suggests an intracranial lesion or infection [10]. On the other hand, patients suffering from migraine usually have had similar headaches in the past, and by definition, one cannot definitively make a diagnosis of migraine without at le




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Infection in an extracranial location (such as the paranasal or mastoid sinuses, pharynx, or inner ear) may serve as a nidus for the development of meningitis or intracranial abscess.
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t definitively make a diagnosis of migraine without at least four prior episodes. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".) ●Concomitant infection – <span>Infection in an extracranial location (such as the paranasal or mastoid sinuses, pharynx, or inner ear) may serve as a nidus for the development of meningitis or intracranial abscess. (See "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Pathogenesis, clinical manifestations, and diagnosis of brain abscess".) ●Altered mental status or se




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Any change in mental status, personality, or fluctuation in the level of consciousness suggests a potentially serious abnormality. Syncope or near-syncope at headache onset is suggestive of SAH. Headache associated with seizure is also concerning for intracranial pathology
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(See "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Pathogenesis, clinical manifestations, and diagnosis of brain abscess".) ●Altered mental status or seizure – <span>Any change in mental status, personality, or fluctuation in the level of consciousness suggests a potentially serious abnormality. Syncope or near-syncope at headache onset is suggestive of SAH. Headache associated with seizure is also concerning for intracranial pathology. Preeclampsia and PRES can cause headache and seizure and may present up to six weeks following delivery. In the patient with a headache and altered mental status, it is important to ch




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
In the patient with a headache and altered mental status, it is important to check for hypoglycemia using a point-of-care (eg, fingerstick) glucose concentration
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of SAH. Headache associated with seizure is also concerning for intracranial pathology. Preeclampsia and PRES can cause headache and seizure and may present up to six weeks following delivery. <span>In the patient with a headache and altered mental status, it is important to check for hypoglycemia using a point-of-care (eg, fingerstick) glucose concentration. (See "Stupor and coma in adults" and "Evaluation and management of the first seizure in adults" and "Preeclampsia: Clinical features and diagnosis".) ●Headache with exertion – The rapi




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Preeclampsia and PRES can cause headache and seizure and may present up to six weeks following delivery.
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sness suggests a potentially serious abnormality. Syncope or near-syncope at headache onset is suggestive of SAH. Headache associated with seizure is also concerning for intracranial pathology. <span>Preeclampsia and PRES can cause headache and seizure and may present up to six weeks following delivery. In the patient with a headache and altered mental status, it is important to check for hypoglycemia using a point-of-care (eg, fingerstick) glucose concentration. (See "Stupor and coma




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
The rapid onset of headache with exertion (eg, sexual intercourse, exercise), raises the possibility of carotid artery dissection, reversible cerebral vasoconstriction, or intracranial hemorrhage.
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se concentration. (See "Stupor and coma in adults" and "Evaluation and management of the first seizure in adults" and "Preeclampsia: Clinical features and diagnosis".) ●Headache with exertion – <span>The rapid onset of headache with exertion (eg, sexual intercourse, exercise), raises the possibility of carotid artery dissection, reversible cerebral vasoconstriction, or intracranial hemorrhage. (See "Headache, migraine, and stroke" and "Exercise (exertional) headache".) ●Age over 50 – Patients over 50 years of age with new onset or progressively worsening headache are at signi




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Patients over 50 years of age with new onset or progressively worsening headache are at significantly greater risk of a dangerous cause of their symptoms, including an intracranial mass lesion and giant cell arteritis [1,3,6,11].
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ility of carotid artery dissection, reversible cerebral vasoconstriction, or intracranial hemorrhage. (See "Headache, migraine, and stroke" and "Exercise (exertional) headache".) ●Age over 50 – <span>Patients over 50 years of age with new onset or progressively worsening headache are at significantly greater risk of a dangerous cause of their symptoms, including an intracranial mass lesion and giant cell arteritis [1,3,6,11]. (See "Clinical manifestations of giant cell arteritis".) ●HIV and immunosuppression – HIV and other immunosuppressed patients with headache are at significant risk for intracranial dise




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
HIV and other immunosuppressed patients with headache are at significant risk for intracranial disease, including toxoplasmosis, stroke, brain abscess, meningitis, and malignancy of the CNS. Clinicians should have a low threshold to perform aggressive workups on such patients, particularly if high-risk features such as new-onset seizure or altered mental status are present [10,12].
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ngerous cause of their symptoms, including an intracranial mass lesion and giant cell arteritis [1,3,6,11]. (See "Clinical manifestations of giant cell arteritis".) ●HIV and immunosuppression – <span>HIV and other immunosuppressed patients with headache are at significant risk for intracranial disease, including toxoplasmosis, stroke, brain abscess, meningitis, and malignancy of the CNS. Clinicians should have a low threshold to perform aggressive workups on such patients, particularly if high-risk features such as new-onset seizure or altered mental status are present [10,12]. (See "Approach to the patient with HIV and central nervous system lesions".) ●Visual disturbances – Occasionally, patients with significant ophthalmologic disease, most notably acute an




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Occasionally, patients with significant ophthalmologic disease, most notably acute angle-closure glaucoma, present with a complaint of headache.
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if high-risk features such as new-onset seizure or altered mental status are present [10,12]. (See "Approach to the patient with HIV and central nervous system lesions".) ●Visual disturbances – <span>Occasionally, patients with significant ophthalmologic disease, most notably acute angle-closure glaucoma, present with a complaint of headache. A careful history and physical examination, including measurement of intraocular pressures, is usually sufficient to determine whether this is the source of pain. Headache may precede v




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Headache may precede visual changes or eye pain in acute angle-closure glaucoma. Headache associated with visual disturbances may also be associated with giant cell arteritis, idiopathic intracranial hypertension, and PRES
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with a complaint of headache. A careful history and physical examination, including measurement of intraocular pressures, is usually sufficient to determine whether this is the source of pain. <span>Headache may precede visual changes or eye pain in acute angle-closure glaucoma. Headache associated with visual disturbances may also be associated with giant cell arteritis, idiopathic intracranial hypertension, and PRES. (See "Angle-closure glaucoma", section on 'Clinical presentation' and "Clinical manifestations of giant cell arteritis" and "Idiopathic intracranial hypertension (pseudotumor cerebri):




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Although primary headache syndromes remain the most common cause of headaches in this group, other pregnancy-related diagnoses should be considered. Preeclampsia is the most common of these; the presentation of preeclampsia can overlap with PRES [13]. Less common etiologies include venous sinus thrombosis, pituitary apoplexy, and reversible cerebral vasoconstriction [13].
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is" and "Idiopathic intracranial hypertension (pseudotumor cerebri): Clinical features and diagnosis" and "Reversible posterior leukoencephalopathy syndrome".) ●Pregnancy and postpartum state – <span>Although primary headache syndromes remain the most common cause of headaches in this group, other pregnancy-related diagnoses should be considered. Preeclampsia is the most common of these; the presentation of preeclampsia can overlap with PRES [13]. Less common etiologies include venous sinus thrombosis, pituitary apoplexy, and reversible cerebral vasoconstriction [13]. Venous sinus thrombosis is most common postpartum. Worse headache upon standing postpartum suggests either a postdural puncture headache (if the patient had a spinal anesthetic) or spon




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Location of the pain is not particularly useful in the diagnosis. However, head pain that spreads into the lower neck (ie, occipitonuchal headache) and between the shoulders may indicate meningeal irritation due to either infection or subarachnoid blood; it is not typical of a benign process [1]
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"Headache during pregnancy and postpartum" and "Preeclampsia: Clinical features and diagnosis" and "Cerebral venous thrombosis: Etiology, clinical features, and diagnosis".) ●Location of pain – <span>Location of the pain is not particularly useful in the diagnosis. However, head pain that spreads into the lower neck (ie, occipitonuchal headache) and between the shoulders may indicate meningeal irritation due to either infection or subarachnoid blood; it is not typical of a benign process [1]. Some secondary headaches are well localized. As an example, headache from acute angle-closure glaucoma is commonly centered around the involved eye, while headache from giant cell arte




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Some secondary headaches are well localized. As an example, headache from acute angle-closure glaucoma is commonly centered around the involved eye, while headache from giant cell arteritis is often, but not always, focused in a temple.
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he lower neck (ie, occipitonuchal headache) and between the shoulders may indicate meningeal irritation due to either infection or subarachnoid blood; it is not typical of a benign process [1]. <span>Some secondary headaches are well localized. As an example, headache from acute angle-closure glaucoma is commonly centered around the involved eye, while headache from giant cell arteritis is often, but not always, focused in a temple. (See "Angle-closure glaucoma" and "Diagnosis of giant cell arteritis".) ●Family history – The headache patient with a family history of SAH among first- or second-degree relatives is at




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
The headache patient with a family history of SAH among first- or second-degree relatives is at significantly greater risk of SAH [14]. Simultaneous headaches in multiple family members suggest carbon monoxide poisoning.
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e involved eye, while headache from giant cell arteritis is often, but not always, focused in a temple. (See "Angle-closure glaucoma" and "Diagnosis of giant cell arteritis".) ●Family history – <span>The headache patient with a family history of SAH among first- or second-degree relatives is at significantly greater risk of SAH [14]. Simultaneous headaches in multiple family members suggest carbon monoxide poisoning. (See "Aneurysmal subarachnoid hemorrhage: Epidemiology, risk factors, and pathogenesis", section on 'Genetic risk'.) ●Medications – Clinicians should inquire about medication use, parti




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
Clinicians should inquire about medication use, particularly anticoagulants, glucocorticoids, oral contraceptives, and analgesics. Use of anticoagulants or nonsteroidal antiinflammatory drugs (NSAIDs), including aspirin, increases the risk of intracranial bleeding.
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in multiple family members suggest carbon monoxide poisoning. (See "Aneurysmal subarachnoid hemorrhage: Epidemiology, risk factors, and pathogenesis", section on 'Genetic risk'.) ●Medications – <span>Clinicians should inquire about medication use, particularly anticoagulants, glucocorticoids, oral contraceptives, and analgesics. Use of anticoagulants or nonsteroidal antiinflammatory drugs (NSAIDs), including aspirin, increases the risk of intracranial bleeding. Another consideration in patients taking anticoagulants is a cerebral venous sinus thrombosis, if the indication for the medication was a venous thrombotic event. Sympathomimetics are a




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
All anticoagulants confer an increased bleeding risk, including bleeding into the brain. Patients on warfarin have a higher risk of intracranial hemorrhage compared with those on direct oral anticoagulants (DOACs), and patients on any oral anticoagulant plus antiplatelet agents have an increased risk compared with those not on these agents. Details pertaining to the risk of bleeding associated with particular medications are provided separately. (See "Risks and prevention of bleeding with oral anticoagulants".)
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ugh a rebound effect (medication overuse headache). (See "Acute treatment of migraine in adults" and "Cerebral venous thrombosis: Etiology, clinical features, and diagnosis".) •Anticoagulants – <span>All anticoagulants confer an increased bleeding risk, including bleeding into the brain. Patients on warfarin have a higher risk of intracranial hemorrhage compared with those on direct oral anticoagulants (DOACs), and patients on any oral anticoagulant plus antiplatelet agents have an increased risk compared with those not on these agents. Details pertaining to the risk of bleeding associated with particular medications are provided separately. (See "Risks and prevention of bleeding with oral anticoagulants".) All anticoagulated patients with head trauma, even minor trauma, should undergo computed tomography (CT). Many patients with a new nontraumatic headache will fall into the older age gro




#Cephalee #Diagnosis #Emergency #Headache #SAU #U2D
All anticoagulated patients with head trauma, even minor trauma, should undergo computed tomography (CT).
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ot on these agents. Details pertaining to the risk of bleeding associated with particular medications are provided separately. (See "Risks and prevention of bleeding with oral anticoagulants".) <span>All anticoagulated patients with head trauma, even minor trauma, should undergo computed tomography (CT). Many patients with a new nontraumatic headache will fall into the older age group for whom imaging is already recommended. Other anticoagulated patients with an intracranial hemorrhage




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A number of illicit drugs, including cocaine, methamphetamine, and other sympathomimetic agents, increase the risk of stroke and intracranial bleeding. If the drugs are used intravenously (IV), brain abscess is another possibility, even in the absence of fever.
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judgment include other known risk factors such as age, hypertension, degree of anticoagulation, and prior stroke or known vascular lesions such as cerebral amyloid angiopathy. ●Illicit drugs – <span>A number of illicit drugs, including cocaine, methamphetamine, and other sympathomimetic agents, increase the risk of stroke and intracranial bleeding. If the drugs are used intravenously (IV), brain abscess is another possibility, even in the absence of fever. (See "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine abuse", section on 'Stroke' and "Methamphetamine: Acute intoxication".) ●Toxic ex




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Headaches that involve multiple family members or coworkers and improve rapidly in the emergency department (ED) without intervention, particularly during winter months, raise the possibility of carbon monoxide poisoning.
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(See "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine abuse", section on 'Stroke' and "Methamphetamine: Acute intoxication".) ●Toxic exposure – <span>Headaches that involve multiple family members or coworkers and improve rapidly in the emergency department (ED) without intervention, particularly during winter months, raise the possibility of carbon monoxide poisoning. (See "Carbon monoxide poisoning".) Additional relevant history — Other historical factors to consider when investigating the cause of headache include chiropractic neck manipulation, to




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Other historical factors to consider when investigating the cause of headache include chiropractic neck manipulation, toxic exposures (eg, carbon monoxide), and comorbidities known to put patients at higher risk for critical secondary causes of headache. Such comorbidities include malignancy with a risk of intracranial metastasis (and possibly increased intracranial pressure [ICP]) and polycystic kidney disease or connective tissue disease, both of which increase the risk of aneurysms with resultant SAH. Jaw claudication suggests giant cell arteritis as the cause of headache.
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ncy department (ED) without intervention, particularly during winter months, raise the possibility of carbon monoxide poisoning. (See "Carbon monoxide poisoning".) Additional relevant history — <span>Other historical factors to consider when investigating the cause of headache include chiropractic neck manipulation, toxic exposures (eg, carbon monoxide), and comorbidities known to put patients at higher risk for critical secondary causes of headache. Such comorbidities include malignancy with a risk of intracranial metastasis (and possibly increased intracranial pressure [ICP]) and polycystic kidney disease or connective tissue disease, both of which increase the risk of aneurysms with resultant SAH. Jaw claudication suggests giant cell arteritis as the cause of headache. (See "Spinal manipulation in the treatment of musculoskeletal pain", section on 'Risks of spinal manipulation' and "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagn




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Recent rash compatible with erythema migrans (picture 1) suggests Lyme meningitis, and concurrent petechial (picture 2) or purpuric (picture 3) rash suggests bacterial meningitis.
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skeletal pain", section on 'Risks of spinal manipulation' and "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis" and "Clinical manifestations of giant cell arteritis".) <span>Recent rash compatible with erythema migrans (picture 1) suggests Lyme meningitis, and concurrent petechial (picture 2) or purpuric (picture 3) rash suggests bacterial meningitis. Postural or positional headache raises concern for spontaneous intracranial hypotension or colloid cyst of the third ventricle. (See "Clinical manifestations of Lyme disease in adults",




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Postural or positional headache raises concern for spontaneous intracranial hypotension or colloid cyst of the third ventricle.
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arteritis".) Recent rash compatible with erythema migrans (picture 1) suggests Lyme meningitis, and concurrent petechial (picture 2) or purpuric (picture 3) rash suggests bacterial meningitis. <span>Postural or positional headache raises concern for spontaneous intracranial hypotension or colloid cyst of the third ventricle. (See "Clinical manifestations of Lyme disease in adults", section on 'Erythema migrans' and "Clinical features and diagnosis of acute bacterial meningitis in adults" and "Spontaneous in




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Headaches that worsen upon standing are usually due to postdural puncture (eg, following a lumbar puncture [LP]) or spontaneous intracranial hypotension (if a procedure violating the dura has not been performed). These headaches are due to low ICP from cerebrospinal fluid (CSF) leaks. Headaches that worsen with cough or Valsalva suggest the possibility of brain tumor or other causes of elevated ICP.
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with headache as a prominent symptom (eg, Lyme disease). (See "Clinical manifestations of Lyme disease in adults" and "Cerebral venous thrombosis: Etiology, clinical features, and diagnosis".) <span>Headaches that worsen upon standing are usually due to postdural puncture (eg, following a lumbar puncture [LP]) or spontaneous intracranial hypotension (if a procedure violating the dura has not been performed). These headaches are due to low ICP from cerebrospinal fluid (CSF) leaks. Headaches that worsen with cough or Valsalva suggest the possibility of brain tumor or other causes of elevated ICP. (See "Primary cough headache" and "Spontaneous intracranial hypotension: Pathophysiology, clinical features, and diagnosis".) High-risk examination findings — The following findings on




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Fever makes a diagnosis of migraine or tension-type headache highly unlikely. Fever may be due to CNS infection or inflammation and may be due to a several-day-old SAH (table 4)
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dings — The following findings on physical examination may suggest a life-threatening cause of headache (table 1). (See "The detailed neurologic examination in adults".) ●Abnormal vital signs – <span>Fever makes a diagnosis of migraine or tension-type headache highly unlikely. Fever may be due to CNS infection or inflammation and may be due to a several-day-old SAH (table 4). Although rare, severe hypertension (diastolic blood pressure ≥120 mmHg) can manifest as headache [7]. Although new hypertension in a previously normotensive patient can be due to pain




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Although rare, severe hypertension (diastolic blood pressure ≥120 mmHg) can manifest as headache [ 7]. Although new hypertension in a previously normotensive patient can be due to pain or anxiety, it may also be a compensatory finding from elevated ICP of any cause.
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vital signs – Fever makes a diagnosis of migraine or tension-type headache highly unlikely. Fever may be due to CNS infection or inflammation and may be due to a several-day-old SAH (table 4). <span>Although rare, severe hypertension (diastolic blood pressure ≥120 mmHg) can manifest as headache [7]. Although new hypertension in a previously normotensive patient can be due to pain or anxiety, it may also be a compensatory finding from elevated ICP of any cause. (See "Moderate to severe hypertensive retinopathy and hypertensive encephalopathy in adults".) ●Toxic appearance – An acutely ill patient complaining of headache who manifests other con




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Obtundation and confusion are not seen in benign headaches and increase the likelihood of meningitis, encephalitis, SAH, or results of a space-occupying lesion.
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as lethargy, altered mental status, poor perfusion, pallor, fever, or sweats, may have a systemic illness or infection that is secondarily affecting the CNS. ●Decreased level of consciousness – <span>Obtundation and confusion are not seen in benign headaches and increase the likelihood of meningitis, encephalitis, SAH, or results of a space-occupying lesion. (See "Stupor and coma in adults".) ●Neurologic abnormalities – The patient with any new focal or nonfocal neurologic abnormality must be evaluated for serious illness. Abnormal findings




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Abnormal findings on neurologic examination remain the single best clinical predictor of intracranial pathology [1,6,15]. The findings may be quite subtle and go unnoticed by the patient (eg, slight pupillary asymmetry, unilateral pronator drift, visual field cut, or extensor plantar response) or pronounced and obvious (eg, unilateral vision loss, ataxia, or seizure).
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a space-occupying lesion. (See "Stupor and coma in adults".) ●Neurologic abnormalities – The patient with any new focal or nonfocal neurologic abnormality must be evaluated for serious illness. <span>Abnormal findings on neurologic examination remain the single best clinical predictor of intracranial pathology [1,6,15]. The findings may be quite subtle and go unnoticed by the patient (eg, slight pupillary asymmetry, unilateral pronator drift, visual field cut, or extensor plantar response) or pronounced and obvious (eg, unilateral vision loss, ataxia, or seizure). (See "The detailed neurologic examination in adults".) Focal neurologic findings can accompany a number of secondary causes of headache, including ischemic stroke, intracranial hemorrha




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Nonfocal alterations in mental status more commonly characterize other secondary causes of headache, including SAH, infectious processes such as meningitis or encephalitis, toxins such as carbon monoxide, and metabolic derangements such as hypoxia
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number of secondary causes of headache, including ischemic stroke, intracranial hemorrhage, brain tumor, brain abscess, acute angle-closure glaucoma, and carotid or vertebral artery dissection. <span>Nonfocal alterations in mental status more commonly characterize other secondary causes of headache, including SAH, infectious processes such as meningitis or encephalitis, toxins such as carbon monoxide, and metabolic derangements such as hypoxia. In the patient with a headache and altered mental status, it is important to check for hypoglycemia using a point-of-care (eg, fingerstick) glucose concentration (hypoglycemia may caus




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In the patient with a headache and altered mental status, it is important to check for hypoglycemia using a point-of-care (eg, fingerstick) glucose concentration (hypoglycemia may cause focal neurologic deficits).
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racterize other secondary causes of headache, including SAH, infectious processes such as meningitis or encephalitis, toxins such as carbon monoxide, and metabolic derangements such as hypoxia. <span>In the patient with a headache and altered mental status, it is important to check for hypoglycemia using a point-of-care (eg, fingerstick) glucose concentration (hypoglycemia may cause focal neurologic deficits). Neurologic abnormalities can also occur with migraine headaches. As an example, a visual field cut in both eyes within the same hemifield bounded by scintillations is characteristic of




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Neurologic abnormalities can also occur with migraine headaches. As an example, a visual field cut in both eyes within the same hemifield bounded by scintillations is characteristic of migraine with visual aura (see "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults", section on 'Migraine aura'). However, a focal neurologic deficit should not be assumed to be related to migraine unless similar deficits have occurred with prior migraines. Any new or atypical focal neurologic deficit is considered a high-risk finding and should be investigated urgently until the cause is identified.
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a headache and altered mental status, it is important to check for hypoglycemia using a point-of-care (eg, fingerstick) glucose concentration (hypoglycemia may cause focal neurologic deficits). <span>Neurologic abnormalities can also occur with migraine headaches. As an example, a visual field cut in both eyes within the same hemifield bounded by scintillations is characteristic of migraine with visual aura (see "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults", section on 'Migraine aura'). However, a focal neurologic deficit should not be assumed to be related to migraine unless similar deficits have occurred with prior migraines. Any new or atypical focal neurologic deficit is considered a high-risk finding and should be investigated urgently until the cause is identified. (See 'Evaluation of patients with high-risk features' below.) One concept that helps to distinguish symptoms or signs due to migraine rather than ischemia, infarct, or other destructive




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One concept that helps to distinguish symptoms or signs due to migraine rather than ischemia, infarct, or other destructive processes is that of "positive" versus "negative" phenomena, as described in the following table (table 5). As a general rule, positive phenomena are due to migraine and seizure whereas negative findings are found in destructive lesions.
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pical focal neurologic deficit is considered a high-risk finding and should be investigated urgently until the cause is identified. (See 'Evaluation of patients with high-risk features' below.) <span>One concept that helps to distinguish symptoms or signs due to migraine rather than ischemia, infarct, or other destructive processes is that of "positive" versus "negative" phenomena, as described in the following table (table 5). As a general rule, positive phenomena are due to migraine and seizure whereas negative findings are found in destructive lesions. ●Meningismus – Meningismus may indicate meningitis or SAH. It can be subtle. This sign is also less sensitive and less specific in adults older than 60 years [16]. (See "Clinical featur




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Meningismus may indicate meningitis or SAH. It can be subtle. This sign is also less sensitive and less specific in adults older than 60 years [16].
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, as described in the following table (table 5). As a general rule, positive phenomena are due to migraine and seizure whereas negative findings are found in destructive lesions. ●Meningismus – <span>Meningismus may indicate meningitis or SAH. It can be subtle. This sign is also less sensitive and less specific in adults older than 60 years [16]. (See "Clinical features and diagnosis of acute bacterial meningitis in adults", section on 'Presenting manifestations'.) ●Ophthalmologic findings – Papilledema, detected by blurring of




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Examination of the eye in acute angle-closure glaucoma often shows an edematous ("steamy") cornea and may reveal ciliary flush (picture 5) and sluggish pupillary light response.
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ss of vision can occur as a result of vascular compromise in giant cell arteritis or carotid artery dissection, or as a result of increased intraocular pressure in acute angle-closure glaucoma. <span>Examination of the eye in acute angle-closure glaucoma often shows an edematous ("steamy") cornea and may reveal ciliary flush (picture 5) and sluggish pupillary light response. Field cuts can be seen with any process that involves the optic nerve, chiasm (especially with pituitary apoplexy), optic radiations (any process), or occipital cortex (PRES or posterio




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Field cuts can be seen with any process that involves the optic nerve, chiasm (especially with pituitary apoplexy), optic radiations (any process), or occipital cortex (PRES or posterior cerebral artery ischemic stroke).
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osure glaucoma. Examination of the eye in acute angle-closure glaucoma often shows an edematous ("steamy") cornea and may reveal ciliary flush (picture 5) and sluggish pupillary light response. <span>Field cuts can be seen with any process that involves the optic nerve, chiasm (especially with pituitary apoplexy), optic radiations (any process), or occipital cortex (PRES or posterior cerebral artery ischemic stroke). (See "Overview and differential diagnosis of papilledema" and "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis" and "Angle-closure glaucoma".) Additional relev




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Abnormalities of the temporal artery (eg, diminished pulse, swelling, or tenderness) are highly suggestive of giant cell arteritis.
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Overview and differential diagnosis of papilledema" and "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis" and "Angle-closure glaucoma".) Additional relevant findings — <span>Abnormalities of the temporal artery (eg, diminished pulse, swelling, or tenderness) are highly suggestive of giant cell arteritis. Nausea and vomiting can accompany increased ICP, intracranial hemorrhage, or acute angle-closure glaucoma but are also common with migraine. Vomiting in a migraineur who has never vomit




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Nausea and vomiting can accompany increased ICP, intracranial hemorrhage, or acute angle-closure glaucoma but are also common with migraine. Vomiting in a migraineur who has never vomited with prior headaches raises concern for a secondary cause of the new headache.
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and "Angle-closure glaucoma".) Additional relevant findings — Abnormalities of the temporal artery (eg, diminished pulse, swelling, or tenderness) are highly suggestive of giant cell arteritis. <span>Nausea and vomiting can accompany increased ICP, intracranial hemorrhage, or acute angle-closure glaucoma but are also common with migraine. Vomiting in a migraineur who has never vomited with prior headaches raises concern for a secondary cause of the new headache. A carotid bruit may accompany carotid artery dissection but is more commonly due to atherosclerotic plaque. Nasal discharge associated with sinus tenderness or signs of dental infection




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A carotid bruit may accompany carotid artery dissection but is more commonly due to atherosclerotic plaque. Nasal discharge associated with sinus tenderness or signs of dental infection may reflect the cause of headache.
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or acute angle-closure glaucoma but are also common with migraine. Vomiting in a migraineur who has never vomited with prior headaches raises concern for a secondary cause of the new headache. <span>A carotid bruit may accompany carotid artery dissection but is more commonly due to atherosclerotic plaque. Nasal discharge associated with sinus tenderness or signs of dental infection may reflect the cause of headache. (See "Diagnosis of giant cell arteritis" and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis" and "Complications, diagnosis, and treatment of odonto




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Approximate effective radiation dose is 2 mSv for a head CT and 4 to 5 mSv for head CTA [18,19].
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ace and maxilla (encompassing the paranasal sinuses), or the temporomandibular joint are sometimes added to the head imaging if an underlying diagnosis that localizes anatomically is suspected. <span>Approximate effective radiation dose is 2 mSv for a head CT and 4 to 5 mSv for head CTA [18,19]. Factors to consider when choosing the appropriate imaging examination include diagnostic performance for the most likely diagnosis, availability of the technology, radiologist expertise




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In addition, the ACR Appropriateness Criteria provides general guidance for many common clinical scenarios of headache [20]. When the decision is not obvious, consultation with the radiologist is helpful to facilitate patient referral.
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logist expertise, and safety considerations. The choice of when to image and with what modality for many suspected etiologies of headache is discussed here and in other related UpToDate topics. <span>In addition, the ACR Appropriateness Criteria provides general guidance for many common clinical scenarios of headache [20]. When the decision is not obvious, consultation with the radiologist is helpful to facilitate patient referral. EVALUATION OF PATIENTS WITHOUT HIGH-RISK FEATURES — Patients with a history of prior headaches who present to the emergency department (ED) due to failure of their standard therapy regi




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Patients with a history of prior headaches who present to the emergency department (ED) due to failure of their standard therapy regimen and who meet the following criteria can be considered at low-risk for dangerous headache:

● No substantial change in their typical headache pattern

● No new concerning historical features (eg, seizure, fever)

● No focal neurologic symptoms or abnormal neurologic or ophthalmologic examination findings

● No high-risk comorbidity

An extensive diagnostic workup and routine imaging in the ED are not needed in these patients [21]. However, some of these patients should be referred for evaluation for non-life-threatening but treatable causes of headache. (See "Evaluation of headache in adults".)

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al scenarios of headache [20]. When the decision is not obvious, consultation with the radiologist is helpful to facilitate patient referral. EVALUATION OF PATIENTS WITHOUT HIGH-RISK FEATURES — <span>Patients with a history of prior headaches who present to the emergency department (ED) due to failure of their standard therapy regimen and who meet the following criteria can be considered at low-risk for dangerous headache: ●No substantial change in their typical headache pattern ●No new concerning historical features (eg, seizure, fever) ●No focal neurologic symptoms or abnormal neurologic or ophthalmologic examination findings ●No high-risk comorbidity An extensive diagnostic workup and routine imaging in the ED are not needed in these patients [21]. However, some of these patients should be referred for evaluation for non-life-threatening but treatable causes of headache. (See "Evaluation of headache in adults".) The yield of imaging is low if no high-risk historical feature is present and the neurologic examination is normal. As an example, a meta-analysis of published articles on the utilizati




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The yield of imaging is low if no high-risk historical feature is present and the neurologic examination is normal. As an example, a meta-analysis of published articles on the utilization of computed tomography (CT) and magnetic resonance imaging (MRI) in patients presenting with headache conducted by the Quality Standards Subcommittee of the American Academy of Neurology revealed that abnormalities were present in only 2.4 percent of patients with a normal neurologic examination [22]. The incidence of pathology was even lower (0.4 percent) in patients whose headaches were typical of migraine and whose physical examinations were normal
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ed in these patients [21]. However, some of these patients should be referred for evaluation for non-life-threatening but treatable causes of headache. (See "Evaluation of headache in adults".) <span>The yield of imaging is low if no high-risk historical feature is present and the neurologic examination is normal. As an example, a meta-analysis of published articles on the utilization of computed tomography (CT) and magnetic resonance imaging (MRI) in patients presenting with headache conducted by the Quality Standards Subcommittee of the American Academy of Neurology revealed that abnormalities were present in only 2.4 percent of patients with a normal neurologic examination [22]. The incidence of pathology was even lower (0.4 percent) in patients whose headaches were typical of migraine and whose physical examinations were normal. Another analysis of 10 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) reported that, of the 14 percent of ED patients with headache who had brain imag




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Another analysis of 10 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) reported that, of the 14 percent of ED patients with headache who had brain imaging at the discretion of the ED provider, 5.5 percent had a "pathological diagnosis" [3].
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h a normal neurologic examination [22]. The incidence of pathology was even lower (0.4 percent) in patients whose headaches were typical of migraine and whose physical examinations were normal. <span>Another analysis of 10 years of data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) reported that, of the 14 percent of ED patients with headache who had brain imaging at the discretion of the ED provider, 5.5 percent had a "pathological diagnosis" [3]. EVALUATION OF PATIENTS WITH HIGH-RISK FEATURES — Once historical and examination criteria have determined those patients with high-risk headache features, further evaluation is performe




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Approximately 8 percent of emergency department (ED) patients with a thunderclap headache have a subarachnoid hemorrhage [8,23]
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l intensity within a few seconds or less than one minute after the onset of pain) is known as "thunderclap headache" because its explosive and unexpected nature is likened to a clap of thunder. <span>Approximately 8 percent of emergency department (ED) patients with a thunderclap headache have a subarachnoid hemorrhage [8,23]. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis" and "Nonaneurysmal subarachnoid hemorrhage" and "Overview of thunderclap headache".) A head computed to




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Because the consequences of missing subarachnoid hemorrhage (SAH) are potentially dire, most guidelines state that an LP should be performed in all patients with suspected SAH in whom the CT is normal. One exception is that if a high-quality CT is obtained within six hours of the onset of symptoms and interpreted by an expert radiologist to be normal, LP is not necessary. These issues are discussed in detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Evaluation and diagnosis'.)
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nderlying cause (most often a cerebral aneurysm or an arteriovenous malformation) with computed tomography with angiography (CTA), magnetic resonance angiography (MRA), or catheter angiography. <span>Because the consequences of missing subarachnoid hemorrhage (SAH) are potentially dire, most guidelines state that an LP should be performed in all patients with suspected SAH in whom the CT is normal. One exception is that if a high-quality CT is obtained within six hours of the onset of symptoms and interpreted by an expert radiologist to be normal, LP is not necessary. These issues are discussed in detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Evaluation and diagnosis'.) Equally important to obtaining appropriate diagnostic testing are initiating actions to prevent acute complications and immediate consultation with a neurosurgeon or other cerebrovascul




HSA
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Equally important to obtaining appropriate diagnostic testing are initiating actions to prevent acute complications and immediate consultation with a neurosurgeon or other cerebrovascular specialist.
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, LP is not necessary. These issues are discussed in detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Evaluation and diagnosis'.) <span>Equally important to obtaining appropriate diagnostic testing are initiating actions to prevent acute complications and immediate consultation with a neurosurgeon or other cerebrovascular specialist. Failure to evaluate patients with thunderclap headache thoroughly and expeditiously can result in misdiagnosis with resultant poor outcomes due to rebleeding, early hydrocephalus, or va




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Failure to evaluate patients with thunderclap headache thoroughly and expeditiously can result in misdiagnosis with resultant poor outcomes due to rebleeding, early hydrocephalus, or vasospasm. Misdiagnosed patients generally appear less ill and do not have neurologic deficits; misdiagnosis stems from a lack of appreciation of the range of possible presentations of patients with SAH and failure to do a CT or LP [14].
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y important to obtaining appropriate diagnostic testing are initiating actions to prevent acute complications and immediate consultation with a neurosurgeon or other cerebrovascular specialist. <span>Failure to evaluate patients with thunderclap headache thoroughly and expeditiously can result in misdiagnosis with resultant poor outcomes due to rebleeding, early hydrocephalus, or vasospasm. Misdiagnosed patients generally appear less ill and do not have neurologic deficits; misdiagnosis stems from a lack of appreciation of the range of possible presentations of patients with SAH and failure to do a CT or LP [14]. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Evaluation and diagnosis'.) Traumatic lumbar puncture — A dilemma sometimes confronted in t




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A dilemma sometimes confronted in the ED is determining what additional workup and disposition are appropriate for patients at risk for SAH whose head CT is unrevealing and whose initial LP is presumed to be traumatic [24]. Several approaches are available to help distinguish between a traumatic tap and true SAH.

First, finding an elevated opening pressure (greater than 20 cm of water) suggests a pathologic process.

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with SAH and failure to do a CT or LP [14]. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Evaluation and diagnosis'.) Traumatic lumbar puncture — <span>A dilemma sometimes confronted in the ED is determining what additional workup and disposition are appropriate for patients at risk for SAH whose head CT is unrevealing and whose initial LP is presumed to be traumatic [24]. Several approaches are available to help distinguish between a traumatic tap and true SAH. First, finding an elevated opening pressure (greater than 20 cm of water) suggests a pathologic process. Of note, the clearing of blood from sequential tubes of CSF is not a reliable means of excluding SAH unless a late or final collecting tube specimen is normal (ie, red blood cell count




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Of note, the clearing of blood from sequential tubes of CSF is not a reliable means of excluding SAH unless a late or final collecting tube specimen is normal (ie, red blood cell count approaches zero). A useful technique to increase the likelihood of obtaining a red cell count in the last tube that approaches zero is to waste several milliliters of CSF between the first and last tubes (this is not harmful, as 10 mL of CSF are produced within 20 to 30 minutes). Another technique is to test for xanthochromia, the presence of which strongly suggests a true SAH (though this too can be falsely positive).
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veral approaches are available to help distinguish between a traumatic tap and true SAH. First, finding an elevated opening pressure (greater than 20 cm of water) suggests a pathologic process. <span>Of note, the clearing of blood from sequential tubes of CSF is not a reliable means of excluding SAH unless a late or final collecting tube specimen is normal (ie, red blood cell count approaches zero). A useful technique to increase the likelihood of obtaining a red cell count in the last tube that approaches zero is to waste several milliliters of CSF between the first and last tubes (this is not harmful, as 10 mL of CSF are produced within 20 to 30 minutes). Another technique is to test for xanthochromia, the presence of which strongly suggests a true SAH (though this too can be falsely positive). Interpretation of CSF analysis is discussed in detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Lumbar puncture'.) Anothe




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Another approach is to repeat the LP one intervertebral level cephalad to where the initial attempt was made (but no higher than L3/4) or under fluoroscopic guidance. The presence of blood in CSF obtained from two LPs suggests SAH, while a normal specimen from the repeat LP makes SAH less likely.
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ely positive). Interpretation of CSF analysis is discussed in detail separately. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Lumbar puncture'.) <span>Another approach is to repeat the LP one intervertebral level cephalad to where the initial attempt was made (but no higher than L3/4) or under fluoroscopic guidance. The presence of blood in CSF obtained from two LPs suggests SAH, while a normal specimen from the repeat LP makes SAH less likely. In cases where suspicion for SAH remains (ie, normal head CT and ambiguous CSF results), we recommend cerebrovascular imaging to resolve the ambiguity. Ideally, this includes head magne




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If bacterial meningitis is considered, blood cultures should be obtained, then empiric antimicrobial therapy (with or without intravenous [IV] dexamethasone) should be instituted (table 6).
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eurysmal subarachnoid hemorrhage".) Suspected meningitis or encephalitis — Fever and altered mental status, with or without nuchal rigidity, can indicate central nervous system (CNS) infection. <span>If bacterial meningitis is considered, blood cultures should be obtained, then empiric antimicrobial therapy (with or without intravenous [IV] dexamethasone) should be instituted (table 6). Management is discussed in detail separately, but in addition to the standard agents for bacterial meningitis, empiric treatment with IV acyclovir for herpes encephalitis and IV doxycyc




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After antibiotics have been given, perform a head CT without contrast to look for contraindications to LP prior to the procedure. A CT prior to a LP is mandatory in the following groups of patients (see "Clinical features and diagnosis of acute bacterial meningitis in adults", section on 'Indications for CT scan before LP'). Note that LP should not be delayed to await a head CT in the absence of these criteria:

● Immunocompromised state (eg, HIV infection, immunosuppressive therapy, solid organ or hematopoietic stem cell transplantation)

● Active CNS disease (eg, acute stroke, mass lesion, abscess) causing intracranial mass effect

● New-onset seizure (within one week of presentation)

● Papilledema

● Abnormal level of consciousness

● Focal neurologic deficit

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host or some resource-limited settings include fungal (eg, cryptococcal) and tuberculous meningitis. (See "Aseptic meningitis in adults" and "Central nervous system tuberculosis: An overview".) <span>After antibiotics have been given, perform a head CT without contrast to look for contraindications to LP prior to the procedure. A CT prior to a LP is mandatory in the following groups of patients (see "Clinical features and diagnosis of acute bacterial meningitis in adults", section on 'Indications for CT scan before LP'). Note that LP should not be delayed to await a head CT in the absence of these criteria: ●Immunocompromised state (eg, HIV infection, immunosuppressive therapy, solid organ or hematopoietic stem cell transplantation) ●Active CNS disease (eg, acute stroke, mass lesion, abscess) causing intracranial mass effect ●New-onset seizure (within one week of presentation) ●Papilledema ●Abnormal level of consciousness ●Focal neurologic deficit In the absence of CT findings that would contraindicate a safe LP (eg, a mass lesion or signs of generalized cerebral edema), one can proceed with LP, measuring the opening pressure. If




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In the absence of CT findings that would contraindicate a safe LP (eg, a mass lesion or signs of generalized cerebral edema), one can proceed with LP, measuring the opening pressure. If LP is contraindicated on the basis of concerning CT findings, the patient should be admitted to an intensive care unit (ICU), antimicrobials continued, and a neurologist consulted.
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acute stroke, mass lesion, abscess) causing intracranial mass effect ●New-onset seizure (within one week of presentation) ●Papilledema ●Abnormal level of consciousness ●Focal neurologic deficit <span>In the absence of CT findings that would contraindicate a safe LP (eg, a mass lesion or signs of generalized cerebral edema), one can proceed with LP, measuring the opening pressure. If LP is contraindicated on the basis of concerning CT findings, the patient should be admitted to an intensive care unit (ICU), antimicrobials continued, and a neurologist consulted. If CT is unavailable and the patient has one or more of the above criteria, we recommend that LP not be performed without obtaining further data, such as CT with contrast or MRI. If CT




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The clinical policy statement on acute headache of the American College of Emergency Physicians makes a recommendation based upon weak evidence that an LP without prior imaging may be performed in patients without signs of increased ICP (ie, papilledema, absent venous pulsations on funduscopy, altered neurologic status, or focal neurologic deficits) [21]. The presence of venous pulsations on funduscopic examination is strong evidence of normal ICP.
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in patients with suspected meningitis found similar results [26]. (See "Clinical features and diagnosis of acute bacterial meningitis in adults", section on 'Cerebrospinal fluid examination'.) <span>The clinical policy statement on acute headache of the American College of Emergency Physicians makes a recommendation based upon weak evidence that an LP without prior imaging may be performed in patients without signs of increased ICP (ie, papilledema, absent venous pulsations on funduscopy, altered neurologic status, or focal neurologic deficits) [21]. The presence of venous pulsations on funduscopic examination is strong evidence of normal ICP. (See "Approach to eye injuries in the emergency department" and "Slit lamp examination".) Focal neurologic deficit or papilledema and new headache — Headache is the primary symptom of i




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Headache is the primary symptom of increased ICP, which should be suspected when accompanied by papilledema, focal neurologic deficit, or repeated episodes of nausea and vomiting without another explanation.
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xamination is strong evidence of normal ICP. (See "Approach to eye injuries in the emergency department" and "Slit lamp examination".) Focal neurologic deficit or papilledema and new headache — <span>Headache is the primary symptom of increased ICP, which should be suspected when accompanied by papilledema, focal neurologic deficit, or repeated episodes of nausea and vomiting without another explanation. Head MRI without and with contrast should be obtained to evaluate for an intracranial mass lesion (eg, primary or metastatic neoplasm, abscess, hematoma), communicating or obstructive h




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If imaging does not reveal a structural cause or anatomical changes associated with elevated ICP, LP is performed to measure the opening pressure and to evaluate for underlying infection. Note that in patients with suspected idiopathic intracranial hypertension, most of whom will have papilledema, an LP with opening pressure is a necessary part of the evaluation, but it should follow brain imaging.
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ndications to both gadolinium-based contrast of MRI and iodinated contrast of CT (eg, eGFR<30 mL/min/1.73 m² and not on dialysis), MRI without contrast is preferred over CT without contrast. <span>If imaging does not reveal a structural cause or anatomical changes associated with elevated ICP, LP is performed to measure the opening pressure and to evaluate for underlying infection. Note that in patients with suspected idiopathic intracranial hypertension, most of whom will have papilledema, an LP with opening pressure is a necessary part of the evaluation, but it should follow brain imaging. (See "Overview and differential diagnosis of papilledema" and "Overview of the evaluation of stroke".) Suspected carbon monoxide poisoning — If carbon monoxide (CO) poisoning is suggest




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If carbon monoxide (CO) poisoning is suggested by the history (eg, multiple family members or coworkers affected simultaneously; patient brought from enclosed space with an identified source such as gasoline or kerosene generator; rapid improvement when removed from source without other intervention), high-flow oxygen should be administered immediately and the diagnosis confirmed by measuring a carboxyhemoglobin concentration with cooximetry using an arterial blood gas sample.
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the evaluation, but it should follow brain imaging. (See "Overview and differential diagnosis of papilledema" and "Overview of the evaluation of stroke".) Suspected carbon monoxide poisoning — <span>If carbon monoxide (CO) poisoning is suggested by the history (eg, multiple family members or coworkers affected simultaneously; patient brought from enclosed space with an identified source such as gasoline or kerosene generator; rapid improvement when removed from source without other intervention), high-flow oxygen should be administered immediately and the diagnosis confirmed by measuring a carboxyhemoglobin concentration with cooximetry using an arterial blood gas sample. Standard pulse oximetry (SpO2) does not differentiate carboxyhemoglobin from oxyhemoglobin. In addition, the partial pressure of oxygen (PaO2) in an arterial blood gas is normal, as it




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Standard pulse oximetry (SpO 2) does not differentiate carboxyhemoglobin from oxyhemoglobin. In addition, the partial pressure of oxygen (PaO2) in an arterial blood gas is normal, as it measures dissolved oxygen (which is not affected by CO), not oxygen bound to hemoglobin (which is). Chronic low-dose CO exposure may also cause headache, more often during winter months.
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intervention), high-flow oxygen should be administered immediately and the diagnosis confirmed by measuring a carboxyhemoglobin concentration with cooximetry using an arterial blood gas sample. <span>Standard pulse oximetry (SpO2) does not differentiate carboxyhemoglobin from oxyhemoglobin. In addition, the partial pressure of oxygen (PaO2) in an arterial blood gas is normal, as it measures dissolved oxygen (which is not affected by CO), not oxygen bound to hemoglobin (which is). Chronic low-dose CO exposure may also cause headache, more often during winter months. (See "Carbon monoxide poisoning".) Suspected acute angle-closure glaucoma — An acute headache accompanied by eye pain or diminished vision, typically unilateral, suggests acute angle-cl




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An acute headache accompanied by eye pain or diminished vision, typically unilateral, suggests acute angle-closure glaucoma (sometimes referred to as acute narrow-angle glaucoma). Examination typically reveals a red eye with ciliary flush and no discharge, a pupil fixed in mid-dilation, and a cornea that is edematous or "steamy" appearing (not normally translucent) (picture 5).
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ound to hemoglobin (which is). Chronic low-dose CO exposure may also cause headache, more often during winter months. (See "Carbon monoxide poisoning".) Suspected acute angle-closure glaucoma — <span>An acute headache accompanied by eye pain or diminished vision, typically unilateral, suggests acute angle-closure glaucoma (sometimes referred to as acute narrow-angle glaucoma). Examination typically reveals a red eye with ciliary flush and no discharge, a pupil fixed in mid-dilation, and a cornea that is edematous or "steamy" appearing (not normally translucent) (picture 5). Elevated intraocular pressure confirms the diagnosis. Unnecessary neurologic workup and imaging delay treatment of this sight-threatening emergency. (See "Angle-closure glaucoma".) Neck




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Headache that radiates into the neck may be the result of carotid or vertebral artery dissection. Horner syndrome is seen in approximately 39 to 47 percent of those with carotid and up to 19 percent of those with vertebral artery dissection [27,28].
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s. Unnecessary neurologic workup and imaging delay treatment of this sight-threatening emergency. (See "Angle-closure glaucoma".) Neck pain and/or Horner syndrome associated with new headache — <span>Headache that radiates into the neck may be the result of carotid or vertebral artery dissection. Horner syndrome is seen in approximately 39 to 47 percent of those with carotid and up to 19 percent of those with vertebral artery dissection [27,28]. Most patients with an arterial dissection do not have a thunderclap headache (3.2 percent for carotid dissection and 9 percent for vertebral dissection) [29]. Nearly 60 percent of patie




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Most patients with an arterial dissection do not have a thunderclap headache (3.2 percent for carotid dissection and 9 percent for vertebral dissection) [29]. Nearly 60 percent of patients have brain ischemia or infarction [29]. However, nearly 10 percent of patients present with isolated headache or neck pain [30]. In the absence of a thunderclap onset, Horner syndrome, or symptoms or signs of brain ischemia or infarction, other clues include recent (even minor) trauma and the history (given by almost all patients with migraine who describe the headache from a dissection) as different from prior headaches [30].
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f carotid or vertebral artery dissection. Horner syndrome is seen in approximately 39 to 47 percent of those with carotid and up to 19 percent of those with vertebral artery dissection [27,28]. <span>Most patients with an arterial dissection do not have a thunderclap headache (3.2 percent for carotid dissection and 9 percent for vertebral dissection) [29]. Nearly 60 percent of patients have brain ischemia or infarction [29]. However, nearly 10 percent of patients present with isolated headache or neck pain [30]. In the absence of a thunderclap onset, Horner syndrome, or symptoms or signs of brain ischemia or infarction, other clues include recent (even minor) trauma and the history (given by almost all patients with migraine who describe the headache from a dissection) as different from prior headaches [30]. Because headache (and neck pain) are so common, establishing the diagnosis of arterial dissection is very difficult in patients who present with pain only (ie, without neurologic findin




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Because headache (and neck pain) are so common, establishing the diagnosis of arterial dissection is very difficult in patients who present with pain only (ie, without neurologic findings) and who do not have any of the clues described above. As it is neither feasible nor desirable to evaluate every such patient with cerebrovascular imaging, occasionally patients may be misdiagnosed on a first visit. This highlights the importance of giving clear, specific discharge instructions about symptoms that should prompt immediate return to the ED.
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, other clues include recent (even minor) trauma and the history (given by almost all patients with migraine who describe the headache from a dissection) as different from prior headaches [30]. <span>Because headache (and neck pain) are so common, establishing the diagnosis of arterial dissection is very difficult in patients who present with pain only (ie, without neurologic findings) and who do not have any of the clues described above. As it is neither feasible nor desirable to evaluate every such patient with cerebrovascular imaging, occasionally patients may be misdiagnosed on a first visit. This highlights the importance of giving clear, specific discharge instructions about symptoms that should prompt immediate return to the ED. Noncontrast head CT should be followed by CT and CTA of the head and neck with IV contrast. Alternatively, MRI and MRA of the head and neck without and with IV contrast is an equivalent




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Noncontrast head CT should be followed by CT and CTA of the head and neck with IV contrast. Alternatively, MRI and MRA of the head and neck without and with IV contrast is an equivalent option. CTA or MRA of the neck extends from the carotid and vertebral artery origins at the thoracic inlet to the circle of Willis at the skull base. Reported accuracies vary somewhat but are similar for CT and MRI. Reported sensitivity ranges from 50 to 80 percent and specificity from 67 to 99 percent for both modalities [31]. (See "Cerebral and cervical artery dissection: Clinical features and diagnosis".)
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ally patients may be misdiagnosed on a first visit. This highlights the importance of giving clear, specific discharge instructions about symptoms that should prompt immediate return to the ED. <span>Noncontrast head CT should be followed by CT and CTA of the head and neck with IV contrast. Alternatively, MRI and MRA of the head and neck without and with IV contrast is an equivalent option. CTA or MRA of the neck extends from the carotid and vertebral artery origins at the thoracic inlet to the circle of Willis at the skull base. Reported accuracies vary somewhat but are similar for CT and MRI. Reported sensitivity ranges from 50 to 80 percent and specificity from 67 to 99 percent for both modalities [31]. (See "Cerebral and cervical artery dissection: Clinical features and diagnosis".) Older adult with new headache — A new or progressively worsening headache in a patient older than 50 years may suggest underlying tumor or hemorrhage. Head MRI without and with contrast




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A new or progressively worsening headache in a patient older than 50 years may suggest underlying tumor or hemorrhage. Head MRI without and with contrast is recommended. If MRI is not immediately available, head CT without contrast is an option to evaluate for findings associated with elevated ICP (eg, hydrocephalus, hemorrhage, and mass effect), and MRI without and with contrast is usually performed when the modality becomes available.
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0 to 80 percent and specificity from 67 to 99 percent for both modalities [31]. (See "Cerebral and cervical artery dissection: Clinical features and diagnosis".) Older adult with new headache — <span>A new or progressively worsening headache in a patient older than 50 years may suggest underlying tumor or hemorrhage. Head MRI without and with contrast is recommended. If MRI is not immediately available, head CT without contrast is an option to evaluate for findings associated with elevated ICP (eg, hydrocephalus, hemorrhage, and mass effect), and MRI without and with contrast is usually performed when the modality becomes available. CT without and with contrast is the second-line option and only performed if MRI is contraindicated or not available at all. If the patient has contraindications to both gadolinium-base




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Infection, lymphoma, and leukemia are complications of chronic immunosuppression. Head MRI without and with contrast should be obtained to evaluate for abscess or encephalitis. If MRI is not immediately available, head CT without contrast is an option to evaluate for findings associated with elevated ICP (eg, hydrocephalus, hemorrhage, and mass effect), and MRI without and with contrast is performed when the modality becomes available.
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t. (See "Subdural hematoma in adults: Etiology, clinical features, and diagnosis", section on 'Clinical manifestations' and "Brain tumor headache".) Immunosuppressed patient with new headache — <span>Infection, lymphoma, and leukemia are complications of chronic immunosuppression. Head MRI without and with contrast should be obtained to evaluate for abscess or encephalitis. If MRI is not immediately available, head CT without contrast is an option to evaluate for findings associated with elevated ICP (eg, hydrocephalus, hemorrhage, and mass effect), and MRI without and with contrast is performed when the modality becomes available. CT without and with contrast is the second-line option and only performed if MRI is contraindicated or not available at all. If the patient has contraindications to both gadolinium-base




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Cancer patient with new headache — Metastases and, if the patient is immunocompromised, infection are the primary concerns in this population. Head MRI without and with contrast is recommended. If MRI is not immediately available, head CT without contrast is an option to evaluate for findings associated with elevated ICP (eg, hydrocephalus, hemorrhage, and mass effect), and MRI without and with contrast is performed when the modality becomes available.
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eal a structural cause or anatomical changes associated with elevated ICP, LP is performed to measure the opening pressure and to evaluate for underlying infection or leptomeningeal metastases. <span>Cancer patient with new headache — Metastases and, if the patient is immunocompromised, infection are the primary concerns in this population. Head MRI without and with contrast is recommended. If MRI is not immediately available, head CT without contrast is an option to evaluate for findings associated with elevated ICP (eg, hydrocephalus, hemorrhage, and mass effect), and MRI without and with contrast is performed when the modality becomes available. CT without and with contrast is the second-line option and only performed if MRI is contraindicated or not available at all. If the patient has contraindications to both gadolinium-base




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New headache in pregnancy — Preeclampsia and eclampsia must be considered as the cause of headache in every pregnant woman over 20 weeks of gestation, in addition to the many other causes of acute headache. Preeclampsia and eclampsia can also occur up to a few weeks postpartum. Cerebral venous sinus thrombosis is another particular concern in the postpartum period
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nd iodinated contrast of CT (eg, eGFR<30 mL/min/1.73 m² and not on dialysis), MRI without contrast is preferred over CT without contrast. Leptomeningeal metastases are another consideration. <span>New headache in pregnancy — Preeclampsia and eclampsia must be considered as the cause of headache in every pregnant woman over 20 weeks of gestation, in addition to the many other causes of acute headache. Preeclampsia and eclampsia can also occur up to a few weeks postpartum. Cerebral venous sinus thrombosis is another particular concern in the postpartum period. Headache in the pregnant or postpartum patient is discussed separately. (See "Headache during pregnancy and postpartum".) Orbital, sinonasal, or oromaxillofacial headache — Diagnostic




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Headache with visual impairment, periorbital pain, or ophthalmoplegia could indicate acute angle-closure glaucoma, infection, inflammation, or tumor involving the orbits or cavernous sinus.
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localizing features to the face in the emergency setting should be pursued in patients with high-risk features. (See 'Identifying high-risk patients' above and "Overview of craniofacial pain".) <span>Headache with visual impairment, periorbital pain, or ophthalmoplegia could indicate acute angle-closure glaucoma, infection, inflammation, or tumor involving the orbits or cavernous sinus. MRI of the head and orbits without and with contrast would be the preferred imaging examination. However, if acute angle-closure glaucoma is suspected, an urgent ophthalmic examination




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Headache of sinonasal origin usually does not require imaging for diagnosis as it is best evaluated with nasal endoscopy performed by an ear, nose, and throat (ENT) specialist as an outpatient.
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n. However, if acute angle-closure glaucoma is suspected, an urgent ophthalmic examination is also indicated. (See "Angle-closure glaucoma" and "Orbital cellulitis" and "Tolosa-Hunt syndrome".) <span>Headache of sinonasal origin usually does not require imaging for diagnosis as it is best evaluated with nasal endoscopy performed by an ear, nose, and throat (ENT) specialist as an outpatient. If intracranial complications of sinus disease are suspected, head MRI without and with contrast is indicated. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestation




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Headache suspected to originate from maxillofacial conditions such as temporomandibular joint (TMJ) disorders or trigeminal neuralgia is best evaluated with head MRI without and with IV contrast, generally as an outpatient. Headache suspected of odontogenic origin is better evaluated with CT, especially in the acute setting. Dental amalgam degrades image quality with both CT and MRI, and in such cases, imaging is likely to be of limited quality.
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anial complications of sinus disease are suspected, head MRI without and with contrast is indicated. (See "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis".) <span>Headache suspected to originate from maxillofacial conditions such as temporomandibular joint (TMJ) disorders or trigeminal neuralgia is best evaluated with head MRI without and with IV contrast, generally as an outpatient. Headache suspected of odontogenic origin is better evaluated with CT, especially in the acute setting. Dental amalgam degrades image quality with both CT and MRI, and in such cases, imaging is likely to be of limited quality. (See "Temporomandibular disorders in adults" and "Trigeminal neuralgia" and "Complications, diagnosis, and treatment of odontogenic infections".) Older adult with temporal artery abnorm




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Older adult with temporal artery abnormalities — Giant cell arteritis should be suspected in patients with temporal artery abnormalities (eg, tenderness, decreased pulsations), particularly if associated with jaw claudication, sudden monocular vision loss, or unexplained fever or anemia. The clinical manifestations, evaluation, and treatment of giant cell arteritis are discussed separately. (See "Clinical manifestations of giant cell arteritis" and "Diagnosis of giant cell arteritis" and "Treatment of giant cell arteritis".)
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es, imaging is likely to be of limited quality. (See "Temporomandibular disorders in adults" and "Trigeminal neuralgia" and "Complications, diagnosis, and treatment of odontogenic infections".) <span>Older adult with temporal artery abnormalities — Giant cell arteritis should be suspected in patients with temporal artery abnormalities (eg, tenderness, decreased pulsations), particularly if associated with jaw claudication, sudden monocular vision loss, or unexplained fever or anemia. The clinical manifestations, evaluation, and treatment of giant cell arteritis are discussed separately. (See "Clinical manifestations of giant cell arteritis" and "Diagnosis of giant cell arteritis" and "Treatment of giant cell arteritis".) DISPOSITION — Patients with high-risk features in whom a secondary cause of headache is discovered are admitted or referred to the appropriate setting. For many patients in whom a secon




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For many patients in whom a secondary cause was suspected but a thorough, appropriate workup was normal, symptomatic treatment and discharge with timely primary care or neurologic follow-up is reasonable.
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and "Treatment of giant cell arteritis".) DISPOSITION — Patients with high-risk features in whom a secondary cause of headache is discovered are admitted or referred to the appropriate setting. <span>For many patients in whom a secondary cause was suspected but a thorough, appropriate workup was normal, symptomatic treatment and discharge with timely primary care or neurologic follow-up is reasonable. However, some patients with worrisome high-risk features (eg, altered mental status, a new hard neurologic deficit or associated seizure), should be admitted for observation and further




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Of note, patient response to analgesics should not be used as a diagnostic tool and should not dissuade performance of lumbar puncture (LP) when indicated by history or examination [32].
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r, some patients with worrisome high-risk features (eg, altered mental status, a new hard neurologic deficit or associated seizure), should be admitted for observation and further consultation. <span>Of note, patient response to analgesics should not be used as a diagnostic tool and should not dissuade performance of lumbar puncture (LP) when indicated by history or examination [32]. TREATMENT OF PAIN FROM UNDIFFERENTIATED HEADACHE IN THE EMERGENCY DEPARTMENT — Relief of symptoms is an important part of management for patients presenting to the emergency department




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Relief of symptoms is an important part of management for patients presenting to the emergency department (ED) with severe headache, even when a thorough workup reveals no clear underlying process. The large majority of these patients will ultimately be diagnosed with either a migraine or cluster headache (table 7). Details of migraine and cluster headache treatment are discussed separately. (See "Acute treatment of migraine in adults" and "Cluster headache: Treatment and prognosis".)
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ic tool and should not dissuade performance of lumbar puncture (LP) when indicated by history or examination [32]. TREATMENT OF PAIN FROM UNDIFFERENTIATED HEADACHE IN THE EMERGENCY DEPARTMENT — <span>Relief of symptoms is an important part of management for patients presenting to the emergency department (ED) with severe headache, even when a thorough workup reveals no clear underlying process. The large majority of these patients will ultimately be diagnosed with either a migraine or cluster headache (table 7). Details of migraine and cluster headache treatment are discussed separately. (See "Acute treatment of migraine in adults" and "Cluster headache: Treatment and prognosis".) For those patients with a primary headache disorder that does not clearly meet criteria for migraine or cluster headache, symptomatic treatment should be provided. Few studies are avail




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For those patients with a primary headache disorder that does not clearly meet criteria for migraine or cluster headache, symptomatic treatment should be provided. Few studies are available to guide empiric management of undifferentiated headache in the ED; treatment remains symptom-based and largely nonspecific. Nevertheless, many of the treatments used for acute migraine headaches provide some relief in patients with a severe undifferentiated headache [33,34].
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r headache (table 7). Details of migraine and cluster headache treatment are discussed separately. (See "Acute treatment of migraine in adults" and "Cluster headache: Treatment and prognosis".) <span>For those patients with a primary headache disorder that does not clearly meet criteria for migraine or cluster headache, symptomatic treatment should be provided. Few studies are available to guide empiric management of undifferentiated headache in the ED; treatment remains symptom-based and largely nonspecific. Nevertheless, many of the treatments used for acute migraine headaches provide some relief in patients with a severe undifferentiated headache [33,34]. The authors of a systematic review of headache management in the ED propose the use of a parenterally administered nonsteroidal antiinflammatory drug (NSAID) and a dopamine antagonist [




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The authors of a systematic review of headache management in the ED propose the use of a parenterally administered nonsteroidal antiinflammatory drug (NSAID) and a dopamine antagonist [2]. Their goal is to relieve pain and allow the patient to return to baseline mental function without drowsiness. In the United States, this treatment would probably be ketorolac 15 to 30 mg intravenously (IV) and prochlorperazine 10 mg. Haloperidol 2.5 to 5 mg IV or chlorpromazine 0.1 mg/kg IV might be used in place of prochlorperazine. Pretreatment with 12.5 mg of diphenhydramine or 1 mg of benztropine is suggested to avoid akathisia.
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ns symptom-based and largely nonspecific. Nevertheless, many of the treatments used for acute migraine headaches provide some relief in patients with a severe undifferentiated headache [33,34]. <span>The authors of a systematic review of headache management in the ED propose the use of a parenterally administered nonsteroidal antiinflammatory drug (NSAID) and a dopamine antagonist [2]. Their goal is to relieve pain and allow the patient to return to baseline mental function without drowsiness. In the United States, this treatment would probably be ketorolac 15 to 30 mg intravenously (IV) and prochlorperazine 10 mg. Haloperidol 2.5 to 5 mg IV or chlorpromazine 0.1 mg/kg IV might be used in place of prochlorperazine. Pretreatment with 12.5 mg of diphenhydramine or 1 mg of benztropine is suggested to avoid akathisia. Two small randomized trials report that low-dose haloperidol is effective for alleviating severe pain due to a benign cause of headache [35,36]. In a small randomized trial, prochlorper




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Two small randomized trials report that low-dose haloperidol is effective for alleviating severe pain due to a benign cause of headache [ 35,36]. In a small randomized trial, prochlorperazine was shown to be as effective as subcutaneous sumatriptan [36]. Treating nausea and vomiting with a parenteral agent such as ondansetron may make the patient more comfortable while other diagnostic and therapeutic steps are occurring.
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ol 2.5 to 5 mg IV or chlorpromazine 0.1 mg/kg IV might be used in place of prochlorperazine. Pretreatment with 12.5 mg of diphenhydramine or 1 mg of benztropine is suggested to avoid akathisia. <span>Two small randomized trials report that low-dose haloperidol is effective for alleviating severe pain due to a benign cause of headache [35,36]. In a small randomized trial, prochlorperazine was shown to be as effective as subcutaneous sumatriptan [36]. Treating nausea and vomiting with a parenteral agent such as ondansetron may make the patient more comfortable while other diagnostic and therapeutic steps are occurring. NSAIDs should be withheld in patients for whom there remains concern for a hemorrhagic cause of headache or who may require a lumbar puncture (LP). For headaches unresponsive to treatme




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NSAIDs should be withheld in patients for whom there remains concern for a hemorrhagic cause of headache or who may require a lumbar puncture (LP)
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eous sumatriptan [36]. Treating nausea and vomiting with a parenteral agent such as ondansetron may make the patient more comfortable while other diagnostic and therapeutic steps are occurring. <span>NSAIDs should be withheld in patients for whom there remains concern for a hemorrhagic cause of headache or who may require a lumbar puncture (LP). For headaches unresponsive to treatment with a combination of NSAID and dopamine antagonist that have some migrainous features (eg, photophobia), dihydroergotamine 1 mg IV may be effec




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For headaches unresponsive to treatment with a combination of NSAID and dopamine antagonist that have some migrainous features (eg, photophobia), dihydroergotamine 1 mg IV may be effective. Other medications used to treat undifferentiated headache in the ED include sumatriptan, olanzapine, metoclopramide, and droperidol [37-39]. Sumatriptan and oxygen are used to treat cluster headache.
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agnostic and therapeutic steps are occurring. NSAIDs should be withheld in patients for whom there remains concern for a hemorrhagic cause of headache or who may require a lumbar puncture (LP). <span>For headaches unresponsive to treatment with a combination of NSAID and dopamine antagonist that have some migrainous features (eg, photophobia), dihydroergotamine 1 mg IV may be effective. Other medications used to treat undifferentiated headache in the ED include sumatriptan, olanzapine, metoclopramide, and droperidol [37-39]. Sumatriptan and oxygen are used to treat cluster headache. The use of injectable opioids is strongly discouraged, but they may be necessary for patients with contraindications to NSAIDs or medications with vasoconstrictive effects (eg, dihydroe




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The use of injectable opioids is strongly discouraged, but they may be necessary for patients with contraindications to NSAIDs or medications with vasoconstrictive effects (eg, dihydroergotamine), or for patients in whom prochlorperazine and diphenhydramine have not been effective.

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medications used to treat undifferentiated headache in the ED include sumatriptan, olanzapine, metoclopramide, and droperidol [37-39]. Sumatriptan and oxygen are used to treat cluster headache. <span>The use of injectable opioids is strongly discouraged, but they may be necessary for patients with contraindications to NSAIDs or medications with vasoconstrictive effects (eg, dihydroergotamine), or for patients in whom prochlorperazine and diphenhydramine have not been effective. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline link