The severe headache emergency – part one
“A patient with a severe headache….,” the dispatcher goes on but you have heard enough. You frown to your partner. You were hoping that the good luck could have brought you something a little more exciting than a headache.
You arrive soon after to find a twenty five year old woman lying in bed. She has the curtains drawn making it difficult for you to assess her clearly. Introducing yourself you ask her how you can help today. She replies that she suffers from migraine and now has one of her terrible headaches. She has followed her normal self treatment plan devised by her doctor for the last few hours but to no avail. This has happened before she tells you.
Before making any interpretation of what might be wrong, complete a thorough assessment and history. Jumping to conclusions allows missing key elements, underestimate the problem and make mistakes. Ignoring a more sinister possibility is a bad error. Before you accept a provisional assessment, a process of reasonable worst case scenario differential needs to be performed.
A migraine is bad for the sufferer. If you were to ask them during an episode you could be reasonably confident that they would tell you there could be no worse problem. But there are worse things that this headache could be. The alternative intracranial pathology must include all stroke including ischemic and haemorrhagic. There are other causes of severe headache of course including infection, particularly of the meninges. The pre-hospital responder doesn’t have to recognise or be able to differentiate between all of the other possible causes but does have to be able to keep these serious options at the forefront of any headache patient assessment.
Headache is common enough in stroke varying with type of stroke and the circulation involved. Around one in three strokes have headache as a sign. Onset can vary from a few days before the stroke actually occurs forming some sort of warning opportunity to a few days after. Headache severity does not necessarily relate to severity of the problem causing it.2,3,5,6,11,12 Most stroke headache will be mild.11 It can also occur with transient ischaemic attack.12 Stroke should be at the forefront of concerns with any headache. Following neurological assessment, if stroke seems possible, the patient treated as if this might be the case until proven otherwise.
In contrast, the headache associated with subarachnoid and intracerebral haemorrhage is more likely to be severe and occur with the onset of the event.12 Subarachnoid haemorrhage (SAH) is more likely to cause a thunderclap headache. Though somewhat easy to imagine, a thunderclap headache can be thought of as being of intensely severe within seconds to minutes.11
This is the main event of sudden onset severe headache. The patient will frequently be younger from around twenty years of age up until around sixty. It is more common the patient will be a woman.4 There may be sudden alteration in consciousness or collapse at onset or soon after. There may be nausea, vomiting, neck pain and occasionally photophobia.12 SAH is frequently fatal. It is commonly caused by the rupture of a cerebral artery aneurysm that has often remained asymptomatic. This makes it imperative that anytime this could be the cause it must not be overlooked.
Survival from SAH depends on a number of variables. The most important include the severity of the bleeding, the time it takes to reach treatment, what that treatment actually is and the underlying health and comorbidities of the patient.14
Acute SAH forms a space occupying lesion trapped within the skull. This rising intracranial pressure on the brainstem vasomotor control promoting vasoconstriction, elevated blood pressure and frequently a compensating parasympathetic bradycardia. As vital signs move outside tolerable limits, autoregulation of normal cerebral blood flow is lost leading to cerebral ischemia.14
The medulla, also in the brainstem, is responsible for control of respiration and vomiting. The loss of regular breathing patterns or persistent vomiting can be anticipated early with any serious presentation. Both will present significant airway and breathing management problems for pre-hospital responders.14
Administering vasodilators such as nitrate therapy can reduce blood pressure but in a rather uncontrolled and unpredictable manner. Reduction in blood pressure in the setting of continued raised intracranial pressure could worsen cerebral blood flow problems. Airway options up to and including rapid sequence intubation may be necessary for airway patency. Just as with traumatic brain injury, the possibility of loss of autoregulation prompts care to avoid inducing any gag or other airway reflex to minimise the impact on intracranial pressure. Avoid advanced airway devices without induction drugs. Give preference for less irritating nasopharyngeal airways over oropharyngeal versions and then only if they are necessary. Anti-emesis can be administered but it may not be effective in stopping this complication.
It is, as is often the case, arguable that the best pre-hospital therapy for any stroke, ischaemic or haemorrhagic, is expeditious transport and to the most appropriate facility. Even if the plan includes advanced airway options, time spent out of hospital is likely to be detrimental to the patient. Once at a stroke receiving facility computerised tomography imaging can be used to identify or exclude haemorrhage as the cause. This can be supported by angiography or magnetic resonance imaging imaging as indicated. Testing of the cerebrospinal fluid can show raised red cell count indicative of haemorrhage.4
Jeff Kenneally www.prehemt.com
2. Cerebral vasoconstriction and stroke after use of serotonergic drugs A. B. Singhal, Caviness, A. F. Begleiter, E. J. Mark, G. Rordorf, W. J. Koroshetz Neurology January 8, 2002; 58(1):130-133
3. Headache in Stroke Karsten Vestergaard, Grethe Andersen, Margrethe Ingeman Nielsen, Troels Staehelin Jensen, Stroke. 1993;24:1621-1624
4. Reversible Cerebral Vasoconstriction Syndrome: An important cause of severe headache Li HueyTan, Oliver Flower Emergency Medicine International Volume 2012, Article ID 303152, 8 pages
5. Headache at Stroke Onset in 2196 Patients With Ischemic Stroke or Transient Ischemic Attack Susanne Tentschert, Romana Wimmer, Stefan Greisenegger, Wilfried Lang, Wolfgang Lalouschek, Stroke 2005;36:e1-e3
6. Headache associated with acute ischemic stroke Maurizio Paciaroni, Lucilla Parnetti, Paola Sarchielli, Virgilio Gallai The Journal of Headache and Pain June 2001;2,(1) pp 25-29
11. Cerebral infarct presenting with thunderclap headache Bengt A. Edvardsson Æ Staffan Persson J Headache Pain (2009) 10:207–209
14. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage Guideline for Healthcare Professionals From the American Heart Association/American Stroke Associationl, E. Sander Connolly, Jr, Alejandro A. Rabinstein, J. Ricardo Carhuapoma, Colin P. Derdeyn, Jacques Dion, Randall T. Higashida, Brian L. Hoh, Catherine J. Kirkness, Andrew M. Naidech, Christopher S. Ogilvy, Aman B. Patel,; B. Gregory Thompson, Paul Vespa, Stroke. 2012;43:1711-1737