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CMN 568 EEXAM 5 WITH COMPLETE SOLUTIONS
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CMN 568 EEXAM 5 WITH COMPLETE SOLUTIONS2024-2025
OTTAWA SAH Clinical Decision Rule:
-100% sensitivity in predicting subarachnoid hemorrhage; pt. presenting to ED c/o acute
nontraumatic headache should be investigated for SAH if they have one or more of the
following:
- 40yearsorolder
- Neckpain/stiffnes
- Witnessed LOC
- Onset during exertion
- Thunder clap headache(instantly peakingpain)
- Limited neck flexion(on exam)
Ipsilateral ptosis + miosis
Horner synfrom + HA = carotid artery dissection
Papilledema or absent retinal venous pulsations
Elevated ICP --> F/U with neuro imaging before LP
HA + HTN + retinal cotton wool spots, flame hemorrhages, and disc swelling
Acute severe hypertensive retinopathy
Older than 60 yrs old + HA
Examine for scalp or temporal artery tenderness
Fever + Acute HA
Meningeal inflamamtion (Kernig / Brudzinski sign); abssence of jolt accentuation of HA
cannot accurately rule out meningitis --> needs LP
Diagnostic imaging for Acute Headache
Non-contrast CT of head --> sufficient to rule out ICH + intracranial masses (exceptions:
lymphoma, toxoplasmosis in HIV+, herpes simplex encephalitis, brain abscess)
,5th most common reason for ED visit
Acute headache
Treatment for migraine
Acute:
NSAIDS (PO, nasal, IM toradol), metoclopramide, dihydroergotamine, triptants (PO,
nasal, SubQ)
PO 5-HT1F receptor agonist (Lasmiditan) --> currently in clinical trials
AVOID morphine / hydromorphone as 1st line therapy
Chronic / new daily persistent HA (unresponsive to other therapy):
Subanesthetic ketamine infusion
Treatment of HA in elderly
Peripheral nerve blocks
Non-pharmacologic tx of migraine / cluster HA
Noninvasive vagus nerve stimulation
Treatment for refractory migraine + pregnancy
Peripheral nerve blocks
1st line tx for cluster headaches
Sumatriptan: SQ, intranasal or inhaled (w/100% O2 via 12-15L/min non-rebreather x 15
min)
Analgesic rebound headache
Ergotamines, triptans, medications containing butalbital, and opioids: result in
medication overuse headache if > 10 days/month
Acetaminophen, acetylsalicyclic acid, and NSAIDS: maybe offenders if taken more than
15 days per month
Psudotumor cerebri
Idiopathic intracranial hypertension
, Prophylactic medications for cluster headache
Lithium: titrate accordign to serum levels
Verapamil: routine ECG to monitor PR interval
Topiramate
Delay for these meds to take effect, use transitional therapy until effective -->
Prednisone: 60mg x 5 days --> gradual withdrawal over 7-10 days. Effective in 70-80% of
patients
Ergotamine tartrate: rectal suppository, PO, SubQ injection
Posttraumatic headache tx
Responds to simple analgesics
What type of headache is worse with lying down?
HA due to intracranial mass
Headache d/t intracranial mass
Get CT/MRI
Redskins when lying down
Awakens the patient at night
Peak in AM after nocturnal recumbency
S/S:
Fever
Night sweats
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