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Red flag !
- 任何突發性嚴重頭痛 Sudden, abrupt, thunderclap
- 伴隨 Seizure, Con's change,
Fever, Neck stiffness, N/V, NE deficit, weight loss
- Post trauma
- 頭痛型態改變 Change of characteristic
- 半夜痛醒
- Onset > 50 y/o
- Progressive
- Worst headache in the life
- Worsen when cough, 彎腰, 用力
- 伴隨眼睛, 耳朵劇痛
- HIV, Cancer hx
- 返診的 Headache XD
Onset of thunderclap headache during periods of exertion raises suspicion for subarachnoid
hemorrhage or arterial dissection of the carotid or vertebrobasilar circulation.
Sentinel, or "warning," leaks with minor loss of blood from the aneurysm are reported to occur in 30-50% of aneurysmal SAHs.
Sentinel leaks produce sudden focal or generalized head pain that may be severe.
Sentinel headaches precede aneurysm rupture by a few hours to a few months,
with a reported mean of 2 weeks prior to discovery of the SAH.
In addition to headaches, sentinel leaks may produce nausea, vomiting, photophobia, malaise, or, less commonly, neck pain.
These symptoms may be ignored by the physician
Consider acute angle-closure glaucoma even when there is no focal ocular complaint,
as the pain can be so severe the patient may fail to localize pain to the eye.
Acute headache with associated vestibular symptoms (vertigo or ataxia)
should be considered a cerebellar hemorrhage until proven otherwise.
Headache alone is a rare presentation of brain tumor
headache worsened by Valsalva maneuver, headache causing awakening from sleep
Secondary
- Infection : Meningitis, Encephalitis, Brain abscess
- Vascular : SAH ( Aneurysm ), ICH ( AVM ), Stroke
Cervical artery dissection (carotid and vertebral arteries) : Delayed onset of neurologic symptoms by several days is common
Cerebral venous sinus thrombosis
- Trauma : EDH, SDH, ICH
- Tumor : Night pain 半夜清晨痛醒, weight loss, old onset headache
姿勢改變, Valsava maneuver
- Pressure :
IICP ( 躺下, 咳嗽 痛 ) Worse in morning, worse with head in dependent position
Pseudotumor cerebri
Intracranial hypotension (low-pressure headache) : post lumbar puncture 腦壓太低 (站坐惡化 / 平躺改善 )
can occur spontaneously or in association with head or spine trauma, MRI : diffuse enhancement of the meninges.
LP : opening pressure < 6 cm H2O
- Substance : Drug overdose or withdrawal, Alcohol, Carbon monoxide
- Metabolic : Hypoxia, Hypoglycemia
- Vasculitis : Giant cell temporal arteritis, 50歲中老年人, 視力下降, Jaw claudication, 顳部搏動性痛, ESR, 做切片
- Others :
Herpse
Glaucoma- 視力模糊, N/V, Red eye, pupil dilated and fixed, ocular pressure > 21 mmHg, although this is usually > 30 mmHg
Myofascial pain
Trigeminal neuralgia
Hypertensive headache : pheochromocytoma, posterior reversible encephalopathy syndrome, hypertensive crisis, preeclampsia, and eclampsia
Sinusitis, TMJ
CO intoxication
Pituitary tumor apoplexy : spontaneous hemorrhage or infarction of a preexisting pituitary adenoma
- 枕神經痛 (Occipital neuralgia)
Paroxysms of lancinating pain at the back of the head, in the distribution of the greater and/or lesser occipital nerve
with hypersensitivity in the distribution of the affected nerve.
Can be due to osteoarthritis or degenerative disease of the upper cervical spine.
Meningitis
- Fever, conscious change, Neck stiffness
頸部僵硬 - 躺著無法用下巴碰胸口, 嚴重時甚至左右轉就會痛
- IICP : Headache, Vomiting, Papilledema
- Cushing reflex : HTN, Bradycardia, Respiratory depression
- Kernig, Brudzinski sign
Kernig's sign is positive when the thigh is flexed at the hip and knee at 90 degree angles,
and subsequent extension in the knee is painful (leading to resistance)
Kernig 先把腳彎 90度 ( Hip flexion )
然後讓 knee extension, extesion 過程中有痛就 +
* Meningeal sign 出現在 : Meningitis, SAH
Vascular
* SAH - Aneurysm :
Acom > Pcom > ICA > MCA
Acute onset
爆炸性, 從來沒這麼痛過
Neck pain, Neck stiffness, Kernig, Brudzinski sign
Diffuse pain ( esp Occipital )
N/V, IICP sign, Conscious change
* 可能破掉前有一些前驅症狀 :
Pcom aneurysm 壓到 CN3 - EOM palsy, Ptosis, Pupil dilated
Seizure
只有 Neck pain/stiffness 卻沒有頭痛的 SAH
反應慢人格怪要懷疑 Altered mental status
看 Pupil 會不會 photophobia
血壓高合併頸部不適要懷疑
* ICH - AVM :
年輕男性
Dizziness, Seizure (若靠近皮質)
Focal neurologic deficit
Primary
The incidence of migraine, cluster, and tension headaches decreases with age
Migraine :
Family History, Female
Usually start in childhood and peak around age 40 years
單側 pulsating, 持續 4-72 hr
N/V, 怕光怕吵
Aura (Scintillating scotoma)
Severity moderate to severe
一些感覺運動異常
有時候忙還好, 一放鬆突然就發作起來
最常見的 Aura 是頭暈 + 視覺盲點
Among the most common aura symptoms are lightheadedness and visual changes (scotoma and scintillations).
Tension :
雙側, 緊壓感
Cluster :
反覆夜間入睡後, 季節性 circadian and circannual pattern
15 -180 mins
年輕男性, 眼窩
單側流淚 + 鼻塞 + 結膜充血
吸 100% O2 改善 (100% oxygen administered at 12 L/min for 15 mins through a non-rebreathing mask)
Mimic dental pain
Indications for Head CT with Contrast in Emergency Radiology
1. Suspect space occupying lesion such as a brain tumour or abscess
on plain CT or on the clinical assessment
2. Suspect cerebral venous thrombosis : CT venogram
3. Suspect carotid or vertebral artery dissection : CT angiogram of the head and neck
4. Distinghishing a traumatic vs. aneurysmal subarachnoid hemorrhage
LQQOPERA :
Location :
Bilateral/Unilateral, Focal/Diffuse
Pulsating ? Tension ? Thunderclap
QOO :
Acute/Chronic onset
Ever before
Symptoms before onset : Aura ? Diplopia ?
Intermittent/Persistent
Duration
Progressive
Severity (Pain score)
Precipitating/Exaggerating/Relieving factors：
Trauma episodes, 怕光怕吵, 失眠, 藥物, 酒精, 姿勢
Associated :
Fever, N/V, Dizziness, Vertigo, Tinnitus, Visual loss
Focal signs (Slurred speech, focal weakness …. )
Seizure, Wight loss
Visual change
Rash, Jaw pain when chewing
* PE :
- NE - CNS, Coordination ( Finger nose )
- Kernig + Brudzinski
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