Imaging in headachesPHILIP CHUI

SAAHIR KHAN

Epidemiology Large study of over 3000 scans showed the following:

0.8% brain tumors

0.2% AV malformations

0.3% hydrocephalus

0.1% aneurysm

0.2% subdural hematomas

1.2% CVA including chronic ischemic processes

Choosing wisely campaign -> routine headaches do not need imaging Incidental findings

Costs, CT w/o contrast is $340 average, with contrast is $840.

Evans RW. Diagnostic testing for migraine and other primary headaches. 2009. Neurology Clinics: 27(2); 393-415.

History and physical AAN Diagnostic instrument

How often do you get severe headaches (ie, without treatment it is difficult to function)?

●How often do you get other (milder) headaches?

●How often do you take headache relievers or pain pills?

●Has there been any recent change in your headaches?

Physical exam Level of consciousness

Cranial nerve testing (esp II, III, IV, VI)

Motor

Reflexes

Meningeal signs

Coordination and gaitSilberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the AmericanAcademy of Neurology. Neurology 2000;55:754–762.

Warning signs First headache with no prior history

CNS infection

Intracranial hemmorhage

Sudden onset reaching intensity in seconds or minutes SAH

Worsening headache pattern Mass lesion

Subdural hematoma

Medication overuse

Focal neuro deficit Mass lesion

Collagen vascular disease

AV malformationLipton RB, Bigal ME, Steiner, TJ et al. Classificationof primary headaches. Neurology. 2004;63(3):427-435.

Warning signs Any change in mental status/personality

Fever or systemic symptoms

Headache with strenuous exercise (esp w/ trauma)

Headache spreading into lower neck/shoulders

New headache in an elderly person

At risk populations Cancer -> metastasis

Lyme -> meningoencephalitis

HIV -> opportunistic infection/tumor

Pregnancy

Cortical vein, venous sinus thrombosis

Carotid dissection

Pituitary apoplexyLipton RB, Bigal ME, Steiner, TJ et al. Classificationof primary headaches. Neurology. 2004;63(3):427-435.

Chronic Headache (>4 weeks)

Acute Headache(sudden onset)

Subacute Headache(gradual onset)

“Worst in Life”

MRI Head with/without

contrast

Typical Migraineunilateral pulsating with n/v

and photo/phonophobia

Atypical Pattern, New Features, or Neurologic Signs

Unilateral with Dissection or

Horner’s Signs

CT Head without contrast

No imaging required

Sinusitis or Mastoiditis

Meningitis/Encephalitisfever, AMS, or meningeal signs

CTA or MRA Head and Neck

Temporal ArteritisAge > 60, ESR > 55, temporal tenderness

MRI Head without contrast

• diffusion-weighted

Immuno-compromised

Pregnancy

*

Jordan JE et al, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® headache. [online publication]. Reston (VA): American College of Radiology (ACR); 2009.Neff, MJ. Evidence-Based Guidelines for Neuroimaging in Patients with Nonacute Headache. Am Fam Physician. 2005 Mar 15;71(6):1219-1222.

Case

A 36 year old female presented to the ED complaining of a sudden, acute onset, vertex headache that radiated into her neck. Symptoms started three hours prior to arrival and she endorsed N/V. The patient had had a similar headache five days prior that resolved with excedrin. The patient had a past history of migraines with aura (scintillating lights followed by nausea and right temporal throbbing headache. The present headache was different in intensity, onset, and location. There was no past medical history. Medications included naprosyn prn for headaches, and birth control pills. The patient neither smoked nor consumed alcohol.

The physical examination as documented on the chart included BP 118/70, RR 16, HR 72, T 97. The patient was alert, cooperative, but appear uncomfortable holding the top of her head. Pupil exam was not documented, cranial nerves were “intact”, gait was “normal”.

A case of sudden, severe headache. Foundation for Education and Research in Neurological Emergencies. Adapted from Ferne.org,.Visited 3/11/15.

Questions 1. A 25-year-old male with no past medical history presents to your internal medicine

clinic for recurrent headaches over the past 6 months. These headaches are described as throbbing, 7/10 in intensity, occurring on the left side of the head, and associated with nausea. He denies fevers, vision changes, loss of consciousness, and weakness or numbness in his extremities. He has had to miss work three times in the past month as a result of these headaches. When he feels the headache coming on, he lies down in a dark quiet room until the headache passes. He has no family history of early stroke, aneurysm, or neurological disorders. He does not drink coffee or alcohol and cannot identify any triggers for his headaches. He has tried acetaminophen, aspirin, and ibuprofen without adequate relief of his symptoms. His physical examination is unremarkable, including no neurological deficits. What is the most appropriate next step?

CT Head without contrast

Check ESR

Prescribe oxycodone as needed for headache

Prescribe sumatriptan as needed for headache

Prescribe topiramate daily

Questions Correct Answer: D

Explanation:

This patient presents with a typical migraine without aura. Imaging (A) is not appropriate, as the patient has no risk factors or warning signs for life-threatening causes of headache and a normal neurological exam. Checking inflammatory markers (B) would be appropriate in the setting of concern for temporal arteritis, but this diagnosis is highly unlikely given this patient’s age. Opiates (C) are not a first-line therapy for migraines. Topiramate (E) would be appropriate for prophylaxis if migraine frequency were greater than twice per week. Sumatriptan (D) is the best choice in this case; it would be contraindicated if the patient had a basilar migraine, hemiplegic migraine, or prolonged aura due to vasoconstrictive effect.

Questions 2. A 40-year-old male presents to your internal medicine clinic for daily

headaches over the past two weeks. The headaches are sharp, 6/10, focused around either eye, and associated with a runny nose. His headache today resolved in the waiting room. He states that he had similar symptoms last year around the same time, which he attributed to seasonal allergies, but he has been taking loratadine without adequate relief of his symptoms. He denies fever, vision changes, weakness, and sensory loss. His medications are loratadine as above and lisinopril for hypertension. His physical examination is unremarkable, including no neurological deficits. What is the most appropriate next step?

CT Head without contrast

Chest X-Ray

Prescribe sumatriptan as needed for headache

Prescribe oxygen as needed for headache

Start verapamil and taper lisinopril as needed

Questions Correct Answer: E

Explanation:

This patient presents with cluster headache. Given his daily symptoms, pharmacological prophylaxis is indicated with verapamil (E). Since he is not currently experiencing a headache, acute abortive therapy with sumatriptan (C) or oxygen (D) is unnecessary. Imaging (A) is not appropriate, as the patient has no risk factors or warning signs for life-threatening causes of headache and a normal neurological exam. Chest X-Ray (B) would be indicated in the setting of concern for Horner’s syndrome caused by a Pancoast tumor, but this patient’s presentation is more consistent with cluster headache.

Questions 3. A 68-year-old female presents to your internal medicine clinic for worsening

headache over the past week. The headache is described as left-sided, sharp, and associated with brief periods of dark vision in the left eye. She denies fever, neck stiffness, and weakness or sensory loss in her extremities. Her only medication is levothyroxine for Hashimoto’s thyroiditis. She has no personal or family history of cardiovascular disease or diabetes. Physical exam is notable for peripheral visual field deficits in the left eye, tenderness in the left temporal region, cranial nerves intact bilaterally, supple neck with no carotid bruit, and regular heart rhythm with no murmurs. What is the most appropriate next step?

CT Head without contrast

MRI/MRA Head and Neck with contrast

Check ESR

Start high-dose prednisone

Consult Rheumatology for temporal artery biopsy

Questions Correct Answer: D

Explanation:

This patient presents with temporal arteritis with visual symptoms concerning for impending blindness. While similar visual symptoms may occur with stroke that would be seen on MRI (B) better than CT (A), this patient’s history and physical exam are more consistent with temporal arteritis. While elevated ESR (B) would be consistent with a diagnosis of temporal arteritis, this patient’s clinical suspicion is high enough to justify immediate treatment (D). Delaying treatment to pursue a biopsy (E) is not appropriate.

Questions 4. A 75-year-old female comes with her daughter to your urgent care clinic 3 days after being

hospitalized for a subarachnoid hemorrhage treated by neurosurgical evacuation and clipping. Her daughter notes that the patient seemed drowsy and could not recognize her when she picked her up for her appointment. When asked if she is having any symptoms, the patient moans and points to her head. Her past medical history is notable for atrial fibrillation previously on coumadin and diabetes. She has no known drug allergies. Her vital signs on presentation to the clinic are T 38.4, HR 103, BP 100/60, RR 24, O2 sat 95% on room air. Physical exam shows a woman in moderate distress, lethargic, oriented to person but not place or time, with photophobia, mild neck stiffness, negative Kernig’s and Brudzinski’s signs, and no focal neurological deficits. Intravenous access is obtained, blood cultures are collected, fluid resuscitation is initiated, and lumbar puncture is performed which shows 150 WBC with 85% PMN, 10 RBC, glucose 45, protein 60 with initial CSF gram stain negative and culture pending. What is the most appropriate choice of empiric treatment?

Vancomycin and piperacillin/tazobactam

Vancomycin, cefepime, and ampicillin

Vancomycin, cefepime, ampicillin, and dexamethasone

Vancomycin, ceftriaxone, ampicillin, and dexamethasone

No empiric therapy indicated, await results of CSF culture

Questions Correct Answer: B

Explanation:

This patient has high clinical suspicion for acute bacterial meningitis in the setting of recent neurosurgery. Empiric antimicrobial therapy should be initiated immediately after lumbar puncture, as a delay in therapy (E) would increase the risk of irreversible neurological damage. The appropriate regimen should include cefepime (B, C) to cover Pseudomonas in the setting of recent neurosurgery and should include ampicillin (B, C, D) to cover Listeria given the patient’s age. Although dexamethasone (C, D) should normally be included if Pneumococcus is suspected, dexamethasone is contraindicated in the setting of recent neurosurgery.

Questions 5. A 23-year-old male with no past medical history presents to your urgent care clinic

after being hit in the head by a baseball pitch while playing for his college team. Four hours ago, he was hit on the right temple by a baseball traveling approximately 90 miles per hour. He lost consciousness for less than 30 seconds, and he denies any confusion or memory loss upon regaining consciousness. After finishing his game, he began to develop a mild headache so he came to the clinic. Currently, he notes a 6/10 throbbing headache worse on the right side associated with nausea, drowsiness, and blurry vision. Physical examination is notable for hematoma overlying right temple but no craniofacial deformities and right pupil 1mm larger than left pupil with horizontal nystagmus on medial gaze but otherwise neurologically intact; the rest of his examination is normal. What is the most appropriate next step in management?

CT Head without contrast

MRI Brain with contrast

Admit to observation for serial neurological exams

Discharge home with instructions to return if symptoms worsen

Lumbar Puncture

Questions Correct Answer: A

Explanation:

This patient presents with epidural hematoma with lucid interval and involvement of CN III. Since the patient has a headache with neurological deficits in the setting of trauma, imaging is indicated, and observation with serial exams (C) or discharge home (D) are not appropriate. CT (A) will confirm the diagnosis; MRI (B) is not necessary. The patient’s presentation is more consistent with epidural hematoma than with subarachnoid hemorrhage, which could be worked up with lumbar puncture (E); in this case, lumbar puncture could precipitate herniation.