Acute Neurology

Headaches
Dr. Ommid Rafie

Population per Neurologist

How Common is Acute

Neurology?

A&E Referrals

MAU Referrals

A week in A&E

Most Common MAU

Presentations

Most Common MAU

Presentations
Epileptic Seizures (35%)
TIA/Stroke (21%)
Headache (14%)
_____________

70%

How many saw a

neurologist?
TIA/Stroke (69%) (150)
Epileptic Seizures (35%) (128)
Headache (14%) (21)

How many didnt?

Headache (86%) (120)
Epileptic Seizures (65%) (235)
TIA/Stroke (31%) (68)

Headaches

Headaches

3% of headaches are referred to secondary care

International Classification

Tension
Episodic or Chronic
Bilateral
Pressing or tightening
Rarely incapacitating, rarely
consulted
Treatment with Paracetamol or
Aspirin (1g) have both been shown to
be effective in 75%
Lifetime prevalence >40%

Migraine without

Unilateral
Aura

Gradual
Builds up over hours
Moderate to Severe
Pulsating
Associated
Nausea/Vomiting
Photo/Phonophobia

Family History

Acute Treatment
Aspirin & NSAID
Triptan
Prochlorperazine/Metoclo
pramide

Prophylaxis
Topiramate 100
Propanolol 160

Costs the UK 2 billion a year

Migraine with Aura

Positive
Transient Hemianopic Disturbance
Spreading Scintillating Scotoma
Parasthesia

Negative
Visual loss
Numbness
Hand/Arm/Face (rarely leg)

Dysphasia

Consider TIA in rapid onset aura with no positive symptoms

50-82% of Migraines are misdiagnosed

Cluster
Severe, Sharp, Abrupt
Strictly unilateral
Agitation & restlessness
-Lacrimation
-Rhinorrhea
-Ptosis
-Nasal congestion
-Rapid onset/Short duration
-15 mins - 3 hours
-Circadian Rhythm

Acute Treatment
High Flow O2
6mg
Subcutatneous
Triptan

Prophylaxis
Verapamil
360mg

Serious
Headaches

Meningitis
Headache
Location Generalised/Frontal
Onset Progressive
Radiation - Neck

Distinguishing features
Neck stiffness
Fever

Subarachnoid hemorrhage
Severe headache of sudden onset
Dizziness
Nausea
Vomiting
CT ASAP plus LP (12 hours after
onset)
If normal consider Thunderclap
headache

Giant Cell Arteritis

Should be considered in those >50
Persistent and diffuse
Abrupt onset
Scalp tenderness
Jaw Claudication
ESR+CRP - -> Biopsy
Negative ESR = Unlikely positive
diagnosis

Angle Closure Glaucoma

FH, Female, Hypermetropia
Signs/Symptoms

Dilated pupil
Impaired vision
Halos around eyes
Dilated pupil

Opthalmic emergency

Raised ICP
Intracranial Tumour
Rarely cause headache
Most common tumour to cause headache is pituitary and is presenting
complaint in 3-4%
More commonly present with cognitive change/seizure

Idiopathic Intracranial Hypertension

Transient visual obscurity

Pulsatile tinnitus
6th Nerve palsy
Blind spot/Papilloedema

Intracranial Hypotension
Most commonly traumatic
Develops on standing
Resolves on lying down

CO Poisoning
Nausea
Vomiting
Dizziness
Weakness
Blurred vision

References
-

NICE Guideline 60853

British Association for the study of headache
SIGN Guideline Diagnosis and Management of Headache in Adults
AmericanHeadacheSociety
Acute Neurological Emergencies in Adults 2002, Association of British
Neurologists
Mechanism of migraine and action of antimigraine medications. Med Clin
North Am. 2001 Jul;85(4):943-58, vi-vii.
Tension-Type Headache - Lars Bendtsen, MD, PhD*, RigmorJensen, MD, PhD
Diagnosis and Management of Giant Cell Arteritis, Royal College of
Physicians
Acute neurological problems: frequency, consultation patterns and the uses
of a rapid access neurology clinic J R Coll Physicians Edinb 2009; 39:296
300 doi:10.4997/JRCPE.2009.402

Questions?