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Serious causes of HA, S&S and management

Brain Tumours

Triad
Other S&S
Headache
Nausea
Vomiting
Worse first thing in the morning
Convul­sions
Valsalva movements make it worse
 
new onset/­change in HA
 
Seizures
 
Confusion
 
Dysphagia
 
Motor Weakness
 
Person­ality Changes
 
Memory Loss

Triad in children

Dizziness
Headache
Vomiting

HEADSMART

 

Temporal Arteritis

S&S
Persistant unilateral throbbing over temporal region + scalp tenderness
Associated with PMR - look for bilateral inflam­matory signs over should­er/hip area
>50y
Severe burning - worse in morning & constant
Malaise, vague aches, pains, weight loss
ESR/CRP elevated

Mangement

Urgent referral (same day) to GP - risk of blindness

Mild Traumatic Brain Injury

Common in teens and young adults
Athletes more at risk - football, boxing, hockey, soccer, MMA, military personnel, victims of domestic abuse, motor accidents

Concussion

- One type of brain injury
- Subcon­cussive injury = traumatic impact to the head that does not result in immediate clinical symptoms
- Simple concussion = progre­ssively resolves after 7-10 days without compli­cations
- Complex concussion = persistent symptoms and Hx of loss of consci­ousness >1 minute, recurr­enc­e/e­xac­erb­ation on exertion, prolonged impairment of cognitive function, seizure
Mechanical insult - complex cascade of bioche­mical dysfun­ction - mitroc­hon­drial dysfun­ction - disrupts brain's neuronal homeos­tasis

Presen­tation

- Headache
- Confusion, light-­hea­ded­nes­s/d­izz­iness, visual distur­bances, tinnitus, lethargy, insomnia, photop­hobia, irrita­bility, mood changes, cognitive diffic­ulties
- Impaired memory & leaning, reduced planning, inability to switch mental tasks, attention deficits, slower inform­ation proces­sing, slowed reaction times
- Symptoms worse with physical exerti­on/­stress
On field assessment of injured athlete = ruling out emergent situations
Palpation of head, neck, face , nose and TMJ for f#/inj­uries
Move fingers and toes - upper and lower sensation, strength and function

Glasgow Coma Scale (GCS)

- 15 point scale

Red flags

- GCS <15
- Deteri­orating mental status
- Potential spinal injury
- Progre­ssive neurol­ogical signs/­sym­ptoms
- Persistent vomiting
- Suspected skull f#
- Seizures
- Coagul­opathy
- Prior neuros­urgery
- Multiple injuries

Questions (Maddocks)

What ground­/fi­eld­/rink are we playing at?
What team are we playing today
What half/q­uar­ter­/period is it?
How far into the game is it?
Which side scored last?
What team did we play last game?
Did we win last game?
- Sideline for evaluation if suspected concussion (motor, sensory, reflex tests, CN evalua­tion, coordi­nation and balance assess­ment)
- Difficulty with these questions = out and not allowed to play
- SCAT3
- Ask about concussion S&S

What to do next

Once concussed patient is out of the game, an attendant should stay with them for 24 hours post concussion
Attendant should observe patient every 4 hours
Should be alert for: worsening ha, irrita­bility, persistent nausea­/vo­miting, diffic­ulting speaking, swallo­wing, tinnitus, SOB, light headiness, numbness, confusion, memory loss, clear CSF discharge from nose/ears, unequal pupils, fever, visual distur­bances, seizures, LOC, easily aroused
Drink only clear fluids for 8-12 hours
No alcohol
Diet should begin light and progress to normal over 24 hours
Sedatives, sleeping pills, aspirin and ibuprofen should be avoided
Avoid physical and mental activity for first 24 hours - school, work, texting, video games, driving, operation of dangerous tools or heavy equipment
Should sleep with head elevated for 24 hours
Follow up assessment - did you hit your head? Lose concio­usness? experience amnesia, loss of memory, disori­ent­ati­on/­con­fusion? Dizziness or unstea­diness? Memory proble­ms/­for­get­ful­ness? Concen­tra­tio­n/a­tte­ntion problems?

Imaging

May be used to rule out Cx injury
Canadian CT head rule - witnessed loss of concio­usn­ess­,am­nes­ia/­dis­ori­etn­ation
MRI for: GCS <15 at 2 hours post injury
>2 episodes of vomiting
>65 or older
Suspected skull f# (haemo­tym­panum, raccoon eyes, CSF otorrh­oea­/rh­ino­rrhoea, battles sign (bruising over mastoid)
Pre injury amnesia >30 mins
Dangerous mechanism of injury - struck by motor vehicle, MVA ejection, fall from >3 feet

Management

- Recovery period = 100 days
- Some patients have post concussion syndrome within 1-2 weeks up to 3 months
- Delayed recovery factors = >4 symptoms
HA >60 hours
Pre-injury HA
Self reported fatigu­e/f­oginess
prior mTBI
Hx of PTSD, ADHD, learning disability
advancing age
no and proximity of concus­sions
Duration of concussion (>10 days)
prolonged loss of consci­ousness (>1 minute)
amnesia
convul­sions
co-mor­bid­ities
Medication
- Allowed to play when:
Complete clearing of symptoms at rest - no pain meds
No symptoms after provoc­ative testing - cycling, running, cardio exercises
Full return of cognitive ability, memory and concen­tration
- Can do light aerobic activity after symptoms resolve if it does not excaberate symptoms then progre­ssive more demanding activity should be considered (70%)
- Multiple concussed patients increased risk of Alzhei­mers, ALS , Suicide, Parkinsons and Dementia
- Assess Parasp­inals - subocc­ipitals
- Patients who worsen/do not show improv­ement after 3-5 days should be referred to a specialist
- EPA/DH­A/M­agn­esium
 

Thunde­rclap HA

S&S
Causes
Mana­gem­ent
Sudden, abrupt Headache - Reaches peak @ 1 hour
SAH
REFER IMMEDI­­ATELY TO HOSPITAL
"­­Worse Headache of their life"
Intrac­­ranial haematoma
DON'T LET THEM DRIVE
"­­Feels as though they are being hit on the back of the head"
Cerebral venous sinus thrombosis
Very Different type of Headache
Cervical Artery dissection
 
Ischaemic Stroke

Meningitis

S&S
Severe Headache
Neck Stiffness
High Fever
Altered Mental State
Photo/­Pho­nop­hobia

Mana­gem­ent

Refer immedi­ately to hospital - dial 999
CRP, FBC, blood cultures, lx puncture

Serious Signs of HA in Children

Present in the morning
Wakes Child at night
No PMHx
No Family Hx
Associated Poor health
Associated Neuro symptoms
Presents unilat­erally
       
 

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