Acute severe headache

Differential Diagnosis

• Trauma
• Primary
  • Crash migraine
  • Cluster headache
  • Benign thunderclap headache
    • Orgasmic cephalalgia
    • Exertional headache
• Vascular
  • Subarachnoid hemorrhage
  • Ischemic stroke
  • Hemorrhagic stroke
    • Hypertensive hemorrhage
  • Arterial dissection
  • Pituitary apoplexy (rare)
• Psychogenic

Investigations

• Glasgow coma scale (GCS)
• Non-contrast CT scan
  • Most sensitive in first 12-24 hours
  • Assesses for hydrocephalus and associated intracranial hemorrhage
• Lumbar puncture
  • Differentiate SAH from traumatic tap
  • Xanthochromia indicates SAH that develops 12 hours and can last 2 weeks
    • Slight yellow tinge
• Vascular imaging
  • CTA is best, followed by MRA
  • Can consider traditional angiogram

Management

• CT neg, LP neg: stop
• CT neg, LP pos: angiogram
• CT neg, LP not done: ???
• Acute non-SAH headache:
  • Normal saline 1L IV
  • Metoclopramide IV
  • Toradol IV/IM/po
  • Avoid narcotics outside of acute