5 Altered Mental Status
7. Medication or toxin exposure 8. Postdrome or “hangover” symptoms
9. Prior response to medication 10. Prior testing and results
Physical Examination
In addition to neurological examination, vital signs, palpation of the sinuses, tem-poromandibular joint and cervical musculature, and auscultation of the carotids are included in the typical evaluations. The neurological examination includes
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Table 6.2. Indications for the Diagnostic Evaluation of Headache Nasty Nine
1. First/worst severe headache 2. Abrupt-onset headache
3. Progressive or changing headache pattern 4. Headache with neurologic symptoms> 1 hour 5. Abnormal examination findings
6. Headache with syncope or seizures
7. New headaches in children< 5 years of age, adults > 50 years of age 8. New headaches in patients with cancer, immunosuppression, or pregnancy 9. Headache worsening with exertion, sex, Valsalva maneuver.
assessments of visual acuity and fields, optic discs, extraocular movements, gait, and segmental sensory, motor, reflex, and coordination exams. Signs of meningis-mus or temporal artery tenderness are investigated in certain circumstances as warranted.
Findings of the history and physical examination dictate appropriate diag-nostic testing. The presence of certain clinical clues, here grouped as the “Nasty Nine,” help alert to the presence of a secondary or “organic” headache disorder (Table 6.2).
Diagnostic Testing
Imaging Studies.Although plain films of the sinuses, temporomandibular joint, or cervical spine are occasionally helpful, brain computerized tomography (CT) or magnetic resonance imaging (MRI) are the imaging studies of choice. A non-contrasted CT scan of the brain is useful in presentations involving abrupt-onset headache or trauma, since acute fracture and blood are best visualized by CT.
MRI scanning due to its greater sensitivity and capability of visualization of the sinuses, posterior fossa, and skull base is preferable for all subacute or chronic pre-sentations of headache. Magnetic resonance angiography may be added in cases where vascular dissection, malformation, occlusion, or aneurysm is suspected.
Lumbar Puncture.Lumbar puncture (LP) is mandatory in cases of possible sub-arachnoid hemorrhage (when neuroimaging alone is only 90% sensitive), infec-tious or neoplastic meningoencephalitis, or pseudotumor cerebri. Cerebrospinal fluid (CSF) is analyzed for cell counts, protein, glucose, cultures, cytology, or spe-cial studies when warranted. In cases of possible hemorrhage, the CSF should be centrifuged to detect the presence of xanthochromia. An opening pressure is recorded in any headache patient undergoing lumbar puncture.
Serum Studies.Serum studies are indicated in specific clinical circumstances. A complete blood count (CBC) is indicated on patients with fever, meningismus, or suspected anemia. An erythrocyte sedimentation rate (ESR) is checked in all individuals over age 50 with new or different headaches. A carboxyhemoglobin level is checked in cases of carbon monoxide exposure, while arterial blood gases (ABGs) are performed in cases where symptoms or signs indicate hypoxia, hyper-capnia, or acidosis. If systemic illness is suspected, liver, renal, and thyroid studies are helpful. Toxicology profiles also are of occasional benefit.
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EKG and EEG.Electro cardiography (EKG) and electroencephalography (EEG) are indicated in cases of headache with any loss of consciousness. The former is routine if performed, while the latter is often done outside the confines of many departments. Appropriate referral will then be necessary.
Intraocular Pressure. In cases of suspected ocular etiology, intraocular pressure should be measured by tonometry or slit lamp.
Differential Diagnosis and Management
Secondary Headache Syndromes
Once a patient has been determined to suffer from a secondary headache disorder, it is imperative that appropriate therapeutic interventions be instituted immedi-ately. The treatment is generally based on the specific etiology for the headache condition and the status of the patient at the time of evaluation.
Subarachnoid Hemorrhage
Subarachnoid hemorrhage (SAH) afflicts nearly 30,000 Americans each year, the majority suffering a ruptured intracranial aneurysm. Such hemorrhages are un-common in children and adolescents, peaking between the ages of 40 to 60. The mortality rate is 50%, with half of survivors severely disabled. Most aneurysms are found in the anterior circulation and the Circle of Willis at the base of the brain, with 20% to 25% of patients harboring multiple aneurysms. Although classically described as “the worst headache of my life,” the abrupt nature of the headache is actually more characteristic than its severity. Syncope or seizure, confusion, neck stiffness, focal deficits, or coma can be presenting features. Approximately half of patients have warning symptoms within a month of rupture, including generalized headache, cranial nerve palsies, and “sentinel bleeds.” Emergency CT is the procedure of choice initially, but if unremarkable (10% of cases), a lumbar puncture is mandatory. A centrifuged sample of CSF will yield a yel-low or “xanthochromic” supernatant that helps differentiate hemorrhage from a traumatic tap.
Treatment of patients with SAH begins with supportive measures and ni-modipine 60 mg orally every 4 hours. Neurosurgical consultation is necessary to determine the optimal timing of angiography and surgery.
Meningitis
Meningitis may result from infectious, malignant, hemorrhagic, or toxic causes.
Symptoms aside from headache may include fever, neck stiffness, photophobia, and nausea, while the presence of Kerning and Brudzinski’s signs on examination may help establish meningeal irritation.
Intracranial Mass Lesions
The headache of an intracranial mass lesion is best characterized by its persis-tent and progressive nature. A history of trauma suggests the possibilities of epidural and subdural hematomas, although subdural hematoma is also seen in cases where trauma is minimal or nonexistent. Brain abscesses may present sub-acutely often with other symptoms suggestive of infection, while brain tumors
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may present with a more chronic picture. (See Chapter 11, “Central Nervous System Infections in Adults.”) Impairment in the level of consciousness, par-ticularly when accompanied by focal neurologic findings or papilledema, is an ominous sign. Emergent CT scanning generally confirms the diagnosis, and im-mediate neurosurgical consultation is warranted. Measures to lower intracranial pressure are reviewed in Chapter 23, “Increased Intracranial Pressure and Herni-ation Syndromes.”
Disorders of CSF Volume or Flow
Both hydrocephalus and pseudotumor cerebri (see Chapters 24, “Idiopathic Intracra-nial Hypertension,” and 25, “Normal Pressure Hydrocephalus”) can present with symptoms and signs of increased intracranial pressure. Acute obstructive hydro-cephalus may present as a sudden increase in intracranial pressure with headache, gait and visual disturbances, incontinence, and syncope. Chronic hydrocephalus and pseudotumor cerebri have a subacute presentation.
The headache of intracranial hypotension is characterized by its postural nature.
It is aggravated in the upright position and often accompanied by complaints of nausea, dizziness, visual change, or neck stiffness. Such headaches may rarely oc-cur spontaneously, but most follow trauma, surgery, spinal anesthesia, or lumbar puncture. Young age, female sex, and large diameter spinal needles are the essen-tial risk factors for a “spinal” headache. Bed rest itself has no impact on the occur-rence. Symptoms last for several days before spontaneous resolution. Treatment generally involves hydration with caffeinated beverages, bed rest, analgesics, and if necessary epidural blood patch placement or surgical repair of a persistent CSF leak.
Cerebrovascular Disease
Acute vascular occlusion, either arterial (stroke) or venous (cerebral vein/sinus thrombosis), may result in acute headache and neurologic symptoms. Symptoms that help distinguish vascular compromise from migrainous aura include rapid development, isolation to a single vascular territory, presence of negative phe-nomena without positive (numbness without paresthesias, visual loss without scintillation) component, and duration greater than 60 minutes.
Arterial dissection can be spontaneous or traumatic in nature and is more com-mon acom-mong migraineurs. Headache from carotid dissection is severe, periorbital, and accompanied by anterior neck pain, transient or persistent neurologic com-plaints, and often a carotid bruit or ipsilateral Horner’s syndrome. Vertebral dis-section often involves posterior headache that may be unilateral, accompanied by neck pain and transient or persistent neurologic complaints. Neuroimaging stud-ies and vascular investigation (angiography magnetic resonance angiography, or ultrasound) are warranted, and anticoagulation or thrombolytic therapy may be necessary in appropriate clinical settings.
Inflammatory Disorders
Giant cell arteritis, or temporal arteritis, is considered in all individuals over age 50 presenting with new or different headaches. Headache occurs in 70% of such patients, often unilateral and temporal, and two characteristic complaints are temporal soreness and jaw claudication. Approximately half present with symp-toms of polymyalgia rheumatica: arthralgias, myalgias, fever, night sweats, and
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weight loss. The most important laboratory finding is an elevated ESR, often in the range of 50–100. Prednisone must be instituted immediately in a daily dose of 1 mg/kg, but admission for intravenous steroids is considered if visual com-plaints of amaurosis or obscuration are registered. A temporal artery biopsy may be arranged within a few days, but this must not delay therapy.
Temporomandibular and cervical spine joint disorders occasionally present with headache. Provocation with joint motion, local joint tenderness with restricted range, and abnormalities on imaging studies may help confirm the diagnosis.
Joint rest and nonsteroidal analgesia are often helpful.
Acute bacterial sinusitis is characterized by headache with facial tenderness and pain, purulent or colored nasal discharge with congestion, and often fever.
Maxillary pain is often in the cheek or upper jaw, ethmoid pain between the eyes, frontal pain in the forehead, and sphenoid pain at the vertex or any other cranial location. Sinus CT scan is more sensitive than plain films. Initial treatment is empiric with 10–14 days of broad-spectrum antibiotics, while frontal or sphenoid sinusitis is often a therapeutic urgency warranting intravenous antibiotics and surgical drainage.
Primary Headache Syndromes Tension-Type Headache
Tension-type headache is the most common headache in the population, afflict-ing 63% of men and 86% of women each year. It is characterized by its steady nature, bilateral location, modest intensity, and paucity of associated symptoms.
Episodic tension-type headache is rarely disabling enough to warrant evaluation in the ED. Chronic tension-type headache, affecting 2% of the population, is more likely to appear due to the frustration exhibited by the afflicted. Simple analgesics and prudent muscle relaxant use are frequently satisfactory for episodic tension-type headache, while patients with the chronic variant must be treated with daily prophylactic medication – most often an antidepressant.
Cluster Headache
Although much more uncommon than tension-type or migraine headaches, clus-ter headache present to the ED due to its marked severity. It afflicts less than 1% of the population, generally men (M:F ratio of 5:1) between the ages of 30 and 50 years. Cigarette smoking is commonly associated with the development of cluster, while alcohol and REM (rapid eye movement) sleep may act as triggers for attacks during cycles of activity. Roughly 10% of cluster patients experience chronic symptoms without remission. The headaches are characterized by se-quential episodes of brief, strictly unilateral, excruciating pain with ipsilateral nasal or orbital autonomic changes. The brevity of each attack (20–120 minutes) is typical and often results in spontaneous improvement prior to full evaluation in the ED. During an acute attack, the examination often reveals a restless, agitated adult with ipsilateral Horner’s syndrome, conjunctival injection, and discharge from the eye or nose.
The pain of an acute cluster headache is first managed with inhalation of 100% oxygen through high-flow face mask. Should this be ineffective, and in the absence of contraindications, the most reliable treatment option is 6 mg of subcutaneous sumatriptan. Ipsilateral sphenopalatine ganglion block can be
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Table 6.3. Contraindication for Triptan/DHE Therapy
Coronary artery disease or Prinzmetal angina Cerebrovascular disease
Peripheral vascular disease
Significant risk factors for vascular disease Uncontrolled hypertension
Pregnancy
Prior serious adverse events reaction with the drug Triptan or ergot/DHE within preceding 24 hours
achieved with the instillation of 4% topical lidocaine in the ipsilateral nostril of a supine patient. At the time of discharge, patients not only should receive such acute measures for future use but should also receive medication to prevent recurrence. A 7- to 14-day course of prednisone (1 mg/kg followed by taper) is often recommended. Standard prophylactic agents such as verapamil, methy-sergide (if sumatriptan is not used), or lithium can be instituted at the same time, with continuation a few weeks beyond cessation of the cluster headache cycle.
Migraine Headache
General Approach.Migraine headache presents to the ED for diagnostic purposes when it is new or different. Such patients require a thorough examination and often neuroimaging studies. However, the much more common presentation is of a patient who describes a migraine refractory to typical measures. If extension beyond 72 hours is identified, the label of status migrainosus is applied.
Once the diagnosis of migraine is confirmed, appropriate therapy is instituted.
Since prophylactic agents for migraine require weeks to establish efficacy, their role in an ED treatment protocol is limited. However, their role in the manage-ment of patients with frequent (2 days per week or more) or disabling migraine must not be ignored. Acute intervention with specific or symptomatic migraine medications remains the focus of ED treatment of migraine, with the goals being complete relief of pain and associated symptoms and a return to normal function if possible.
Nonpharmacologic measure, which assists in treatment, should be employed immediately. Attempts to create a quiet, dark, cool environment are helpful. Local application of ice may ease the discomfort. Intravenous hydration itself is often therapeutic, restoring electrolyte balance and reversing dehydration.
Migraine-Specific Therapy.Migraine-specific therapeutic intervention is the next step in management. Two injectable preparations are presently available:
subcutaneous sumatriptan and intravenous or subcutaneous dihydroergotamine.
In the absence of contraindications (Table 6.3), these agents are the drugs of choice for refractory migraine.
Sumatriptan is a selective serotonin (5-hydroxytryptamine) receptor agonist that rapidly relieves the pain of migraine while also improving nausea, photo-phobia, phonophobia and restoring normal function. It works directly on key elements in the pathogenesis of migraine, reversing the dilation of intracranial arteries while also blocking release of vasoactive and inflammatory peptides from
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activated trigeminal nerve terminals. Approximately 80% of patients respond, often within 10–20 minutes. Its strengths include speed, ease of administration, overall efficacy, and reversal of the entire symptom complex of migraine. It re-quires no premedication, is neither sedating nor addictive, and may easily be administered at home. Weaknesses include transient flushing, dizziness or chest pressure, relative expense, and recurrence of headache in up to 40% of patients.
Such recurrences often respond to a second dose of the drug or symptomatic therapies.
Dihydroergotamine, or DHE-45, is another extremely useful agent in the ter-mination of refractory migraine. Although it is delivered intramuscularly or sub-cutaneously, it is most effective when given intravenously. In order to limit an exacerbation of nausea, pretreatment with 10 mg of intravenous metoclopramide or prochlorperazine is advised. A dose of 0.5 mg DHE-45 can be delivered intra-venously 15–30 minutes later. If the headache persists, a second dose of 0.5 mg DHE-45 may then be administered in an additional 30 minutes. This regimen is superior to butorphanol and meperidine/hydroxyzine combinations in clini-cal trials. Strengths include efficacy of 80% and, like sumatriptan, a reversal of all symptoms of migraine. Its weaknesses include a requirement for premedica-tion, a recurrence rate of up to 26%, and side effects including muscle/abdominal cramps, diarrhea, chest pressure, and nausea.
Nonspecific Pharmacologic Therapy.If migraine-specific therapies are con-traindicated or unsuccessful, nonspecific agents are then employed. Table 6.4 outlines the various therapeutic options available. In addition to their role as antiemetics when administered with other migraine medications, prochlorper-azine, metoclopramide, chlorpromprochlorper-azine, and promethazine are themselves effective in reducing or eliminating migraine pain. This effect appears to occur exclu-sively with parenteral administration. Controlled trials have established efficacy similar to that of DHE-45 and ketorolac given intramuscularly, and superior to that of meperidine or lidocaine given intravenously. Sedation, anxiety, motor restlessness, acute dystonia, and occasional hypotension with chlorpromazine are the most common adverse events.
A number of traditional approaches to acute migraine management have less convincing data. Intramuscular ketorolac provided relief of migraine headache in several clinical trials. It is avoided in patients with renal or gastrointestinal disease, and nausea may require codelivery of an antiemetic. Two small studies have investigated the use of intravenous dexamethasone for acute treatment of migraine, and there is extensive anecdotal support. Parenteral corticosteroid is followed by a rapid taper (dexamethasone 12 mg, 8, mg, 4 mg) over 3 days. In-travenous diphenhydramine, diazepam, lidocaine, and magnesium all have primarily anecdotal or open-label data.
A relatively new approach has garnered interest in emergency departments around the country. Intravenous valproate has been shown to abort migraine attacks with great speed and minimal side effects, but the data remain pre-liminary. Occipital nerve blockade may also help abort an intractable migraine attack.
Cardiotoxicity (prolongation of Q-T interval) has been recently reported with the use of droperidol.
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Table 6.4. Acute Migraine Management A. Nonpharmacologic steps
1. Bedrest in quiet, dark, cool environment 2. Local application of ice
3. Intravenous hydration
B. Migraine-specific therapy (if no contraindication) 1. Sumatriptan, 6 mg SQ (may be repeated in 1 hour)
2. Dihydroergotamine, 0.5 mg IV (may be repeated in 30 minutes)
• Premedication required: Metoclopramide 10 mg IV or
Prochlorperazine 10 mg IV C. Nonspecific pharmacologic therapy
1. Neuroleptic agents
• Prochlorperazine, 10 mg IV
• Metoclopramide, 10 mg IV
• Chlorpromazine, 12.5–25 mg IV (slowly) or 25–50 mg IM
• Promethazine, 25–50 mg IV
• Droperidol, 2.5 mg IV (slowly) (may repeat every 30, minutes up to 10 mg) 2. Ketorolac, 30–60 mg IM
3. Dexamethasone, 6–10 mg IV 4. Valproate 300–1000 mg IV 5. Occipital nerve blockade
• Local anesthetic/saline delivery 6. Narcotic analgesics
• Butorphanol, 2 mg IM
• Meperidine, 75–100 mg IM 7. Other agents
• Diphenhydramine, 50–100 mg IV
• Magnesium sulfate, 1 g IV
Role of Narcotics.Given the wide array of newer treatment options for acute migraine, the role of narcotics has become more limited. However it is compas-sionate and necessary to treat occasional patients who have failed all reasonable options with potent narcotic analgesics. Studies have documented equivalent effi-cacy of intramuscular butorphanol and meperidine/hydroxyzine. The risks of narcotic management are analgesic rebound and chemical dependence, so such treatment must be minimized. Should injections be required monthly or more frequently, other steps to manage headache must be taken.
PEARLS ANDPITFALLS
■ Focus on “new” or “different” headaches, not merely the “worst” attacks.
■ Hemorrhagic and traumatic spinal fluids are best distinguished by the presence of xanthochromia.
■ All suspected cases of subarachnoid hemorrhage require CT and LP.
■ New or different headaches in patients over age 50 should generate suspicion for temporal arteritis and an immediate ESR evaluation.
■ Most migraine headaches may be aborted with parenteral sumatriptan, dihydroergo-tamine, or neuroleptic agents.
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SELECTED BIBLIOGRAPHY
Barton CW. Evaluation and treatment of headache patients in the emergency depart-ment: a survey. Headache. 1994;34:91–4.
Couch JR. Headache to worry about. Med Clin North Am. 1993;77:141–65.
Edmeads JF. Emergency management of headache. Headache. 1998;28:675–9.
Ferrari MD, Haan J. Acute treatment of migraine attacks. Curr Opin Neurol. 1995;8:
237–42.
Klapper JA, Stanton J. Current emergency treatment of severe migraine headaches.
Headache. 1992;32:143–6.
Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache. 1993;33:82–6.
Silberstein SD. Evaluation and emergency treatment of headache. Headache. 1992;
32:396–407.
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7 Weakness
George A. Small and David M. Chuirazzi
INTRODUCTION
Weakness is a condition involving muscles that cannot exert a normal force. This is in contrast to fatigue, a vague complaint that is best defined as a diminution in
Weakness is a condition involving muscles that cannot exert a normal force. This is in contrast to fatigue, a vague complaint that is best defined as a diminution in