J Picagli N612 Differential Diagnosis Algorithm

Headache
I. Recent Trauma to Head or Neck? (if no, continue to B)
A. yes, recent known procedure
1. lumbar puncture
a) check for CSF leakage vs known side effect = post-LP headache
2. imaging with contrast agent OR general anesthesia
a) headache due to exposure to medication
b) post-operative pain medication wearing off
c) positional from procedure or appliances
3. craniotomy
a) post-craniotomy headache, incisional pain, post-op medication wearing
off
B. yes, recent trauma
1. GCS = 15
a) monitor for neurological changes, seizure, also evaluate non-head
injuries
(1) concussion
(2) if patient is predisposed to migraine, cluster, tension HA, injury
may trigger preexisting HA
(3) patients on ETOH, antiplatelet meds, anticoagulants, cocaine;
with preexisting seizure disorder, diabetes, have higher risk of bleeding
including delayed hematoma or hemorrhage formation.
(4) 'point' injuries with referred pain to rest of head from tooth loss,
skin/muscle layer trauma
2. GCS 9-14
a) stabilize vital signs: SBP > 90, PaO2 > 60; monitor for shock
b) send to imaging
3. GCS < 8 OR any acute change in GCS > 2 points OR new anisocoria
a) intubate and stabilize as in b.1. above
b) send to imaging
(1) b & c epidural hematoma vs subdural hematoma vs
intracerebral hemorrhage
4. trauma to neck or shoulder
a) neck involvement or falls CT head & spine
(1) spinal cord injury
(2) fracture without CNS involvement
b) arterial dissection
c) neuropathic headache
d) muscle strain / overuse
II. No recent trauma
A. new onset headache
1. gradual onset
a) neck stiffness and/or fever
(1) yes: start abx and send CBC, influenza swab, strongly consider LP
for meningitis vs encephalitis vs SAH vs CNS arteritis vs sinusitis vs
influenza vs other causes of sepsis/shock (CNS arteritis will have joint
pain, elevated WBC in LP; SAH will have blood in LP; bacterial infections
may have decreased glucose in LP)
(2) yes, with rash: start abx, send Ab panels and influenza swab to r/o
tickborne encephalitis (in endemic areas) vs influenza
b) with nausea/vomiting and/or photophobia and/or phonophobia:
(1) first migraine
c) with vision changes
(1) papilledema: hypertension vs brain tumor or cyst vs glaucoma
(2) with visual field loss: first retinal migraine vs optic neuropathy vs
tumor in optic nerve region vs temporal arteritis (send sed rate, CRP to
r/o arteritis; may also be elevated in tumor; consider starting prednisone
in pts over 50 or with other risk factors while arranging biopsy or
imaging; retinal migraine may be considered a dx of exclusion)
d) personality changes
(1) brain tumor or cyst vs stroke/TIA (send to imaging)
e) preexisting HIV or autoimmune disease
(1) opportunistic infection (meningitis, encephalitis) vs tumor (BW, LP
or imaging)
f) preexisting cancer
(1) metastasis vs opportunistic infection vs hemorrhage (send to
imaging)
g) 3-21 days after diagnosis of SAH
(1) transcranial doppler for meningial irritation vs vasospasm after
SAH. Vasospasm may lead to secondary ischemia and prevention by
maintaining SBP is key.
2. sudden onset
a) neck stiffness
(1) yes: start abx and send CBC, send to imaging and consider LP for
meningitis vs subarachnoid hemorrhage vs unruptured aneurysm vs
carotid artery dissection
(2) no, with quick resolution
(a) first cluster headache vs trigeminal neuralgia
b) vision changes
(1) auscultate carotids, take BP, do NIHSS to evaluate carotid
dissection vs hypertensive crisis vs ischemic stroke
c) with loss of consciousness or seizure
(1) strong suggestion for subarachnoid hemorrhage, send to imaging
ASAP
d) other focal neurological losses
(1) evaluate for stroke, TIA, send to imaging within 30 min.
e) preexisting abnormal coaguable state (including cancer, pregnancy, DM,
afib...)
(1) hypercoaguable: work up for stroke/TIA vs other CNS thromboses
(send to imaging)
(2) hypocoagulable: consider imaging vs LP to evaluate for
hemorrhage
3. externally caused secondary headaches
a) generally evaluate by history: altitude changes, hypoxemia, dehydration,
barotrauma in patients with acute URI, exposure to gases, exposure or
withdrawal from medication or drugs or alcohol, known side-effect of dialysis,
post-ictal phase from generalized seizures
B. recurring headaches
1. new type of headache or headache with unusual characteristics in patients w/
headaches
a) neck stiffness
(1) subarachnoid hemorrhage
b) radiation to jaw
(1) EKG to rule out MI
2. similar to previous headaches, but worse
a) worsening of migraine, tension headache vs medication withdrawal vs
medication overuse rebound headache
3. unilateral
a) frequency/duration
(1) very short but very frequent (8-hundreds daily)
(a) restlessness and/or ipsilateral miosis, ptosis, sweating,
tearing, congestion
(i) cluster headache
(b) with response to indomethacin: paroxysmal hemicrania
(c) without either of the above: primary stabbing type of
headache vs neuralgia
(2) intermittent, hours to days
(3) with nausea/vomiting and/or photophobia and/or phonophobia
(a) migraine
(4) with visual field loss
(a) retinal migraine vs temporal arteritis vs optic neuropathy
(Gelb, 2005)
(5) in women, monthly, correlating to menstrual cycle
(a) estrogen withdrawal headache or migraine (may be more
common in some women on oral contraception; continual use or
depositional form may reduce/eliminate)
4. bilateral or diffuse or band-like
a) tension headache vs migraine (may be related to muscle or psychosocial
stress; 30% of migraines are not unlateral) (Manzoni and Torelli, 2004.)
b) medication withdrawal headache
c) if with cough or vagus nerve stimulating activities
(1) imaging to r/o Chiari Malformation
d) if with nasal or ear sense of fullness, head congestion
(1) sinus headache (imaging may be appropriate if > 3 cases/year)
e) if always on awakening
(1) if improvement with sitting up
(2) consider all causes for increased ICP, will require imaging:
hydrocephalus vs tumor/cyst
(3) if worse when sitting up
(a) MRI or LP for low CSF headache
(4) no change
(5) obstructive sleep apnea vs hypnic headache vs migraine (sleep
study for diagnosis of OSA; hypnic headache responds to
lithium)(Manzoni and Torelli, 2004.)
5. scalp or temple region tenderness, and/or joint pain
a) send SED, CRP to r/o giant cell arteritis
6. triggered by head or face stimulus
a) trigeminal neuralgia vs cold-stimulus headache (trigeminal neuralgia
may be a presenting symptom of multiple sclerosis, especially with other
neuralgias and/or visual changes)
7. if irregular and with hypertension
a) hypertensive exacerbation vs pheochromocytoma (pheo workup is 24h
urine collection for catecholamines in hypertensive patient.)


NB: TIA vs stroke: TIA symptoms should resolve within 24h (Gelb, 2005.)



References:

Bajwa, Z. H., & Wootton, R. J. (2012). Evaluation of headache in adults. In D. S. Basow (Ed.), UpToDate.
Waltham, MA:UpToDate.
Gelb, D. J. (2005). Introduction to clinical neurology. Philadelphia, PA: Elsevier.
Graham J. (2004). Chapter 141. Headache and Facial Pain. In O.J. Ma, D.M. Cline, J.E. Tintinalli, G.D.
Kelen, J.S. Stapczynski (Eds),Emergency Medicine Manual, 6e. Retrieved April 28, 2012 from
http://www.accessemergencymedicine.com/content.aspx?aID=1949.

International Headache Society. (2004). International classification of headache disorders, version
2. Retrieved April 28, 2012, from http://ihs-classification.org
Manzoni, G. C., & Torelli, P. (2004). Headache screening and diagnosis Springer Milan.
doi:10.1007/s10072-004-0300-x
Marchioni, E., & Minoli, L. Chapter 52 - headache attributed to infections: Nosography and differential
diagnosis. Handbook of clinical neurology (pp. 601-626) Elsevier. doi:10.1016/S0072-9752(10)97052-8
Nahas, S. J. (2011). Diagnosis of acute headache. Current Pain and Headache Reports, 15, 94-97.
Phan, N., & Hemphill, J. C. (2012). Management of acute, severe traumatic brain injury. In D. S. Basow
(Ed.), UpToDate. Waltham, MA: UpToDate.
Sendovski, U., Rabkin, Y., Goldshlak, L., & Rothmann, M. G. (2009). Should acute myocardial infarction
be considered in the differential diagnosis of headache? European Journal of Emergency Medicine, 16,
1.