FMOE: How To Not To Screw Up Headache Patients

Headaches are a very common complaint in the ED--3 to 5%--and only about 1% of those have a serious underlying cause such as meningitis, subarachnoid or intracranial hemorrhage, mass effect, carbon monoxide poisoning, or hypertensive encephalopathy, according to Rosen's, the bible of EM I'm working my way through.

This morning I had a oh crap in retrospect moment wondering if I missed something, so I'm going to use a case to illustrate how to go after this problem.

48-yo african-american female with hypertension, comes in with a BP of 202/104, a dull HA on the top of her head with no focal neurologic deficit for 2 days. How do I decide if this is a scary headache or not? My gut says not. So?

Red Flags:

1: sudden onset.

2. "The worst headache of my life."

3. altered mental status.

4. true meningismus. See this post for what 'true' means.

5. unexplained abnormal vital signs.

6. focal neurological deficits.

7. worsening under observation.

8. new onset of headache with exertion.

9. history of HIV.

She didn't have any of these, although the hypertension was a bit worrisome. Still, it's in her history so not 'unexplained'. So I have a textbook backing me up. That helps me avoid badness. Now, are there signs that she's all clear?

All Clear Signals:

1. previous identical headaches.

2. normal alertness and cognition for exam and for history.

3. normal neck exam. Our Brit attending does this well. Patient actively ranges chin to chest and looks up, looks side to side. Then, he supports the neck and asks the patient to go all floppy. He then gently but quickly turns the head side to side, for so-called 'jolt accentuation'.

4. normal vital signs.

5. normal or nonfocal neurologic exam.

6. improvement under observation.

The trick is that the patient gets flagged if they have any one of the red flags, and cleared only if they have all of the all clear signs, and she doesn't have normal vitals. So we observed this patient, and worked her up for hypertensive emergency--hypertension with evidence of end-organ damage by altered mental status, EKG changes, or elevated creatinine. Three hours later, after diltiazem, which she had not been taking for four days, and a gram of tylenol (which by the way is a wonder drug), she was better. Bye bye. The only thing bugging me was an EKG finding--she had mildly inverted T-waves in V4, V5, and V6 in the setting of left ventricular hypertrophy--enlargement of the heart due to the increased pressure it has to push against in the setting of hypertension. Why would that bug me? Because a web search of EKG findings in sub-arachnoid hemorrhage, the kind of headache I was worried about in her, showed inverted T-waves in V4, V5, and V6! Oh no, right?

Not really. This is like that 'true' meningismus or 'true' guarding. Inverted T-waves occur after major neurological events that should manifest themselves on exam, and are more impressive--see this example at a great ECG wiki site. Plus, these changes can even be seen during migraine headaches, a common and NOT life threatening presentation in the ED. Last but not least, the wiki site mentions deep T iversion in the precordial leads, i.e., V1 and V2, which correspond to the septum of the heart. This lady's EKG finding was in the leads corresponding to the anteriolateral portion.

So does LVH cause inverted T's? Sure does. See this link, first example. Phew. Fare well, nice headache lady. PLEASE take your diltiazem as instructed by your primary doc. Next time I might see inverted T's in you with altered mental status and severe, thunderclap headache, seeing as how you have hypertension too...sometimes I feel like I'm a pappa bird watching tiny little baby birds jump out of the nest when I discharge. I'll have to get over that, I suppose. Get jaded for my own protection. We'll see how it goes.

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