Lets talk about Headache in Adults!

From the Desk of Sagar Galwankar, MBBS, DNB, FACEE, MPH, Diplomat. ABEM, FRCP

• Headache is one of the common symptoms when patients come to the ED.
• Headache can be a Presenting Complaint when the patient arrives. "I got a Headache" and sometimes when patients are being evaluated at bedside for some other symptoms they can add the complaint "..and I also have an Headache"
• History takes paramount importance when a patient complains of Headache as a Primary Symptoms or a Co-Symptom as a part of a Series of Complaints.
• Always evaluate Headache keeping a 360 Degree approach. 
• Always address Headache. via your Thought process, History taking and Clinical Exam.

Vital Signs take a Lot of Importance and ask for them as you immediately prescribe pain medications to treat the PAIN.

Temperature, Pulse, Blood Pressure, Respiration, Pulse Ox, and Bedside Glucose are key stat Bedside Parameters which guide you to a story. Order an EKG Stat and read it.

Remember:  Gender does matter ! Pregnant Females & Females who do not know they are pregnant can come to the ED. Being Pregnant Changes the way you will evaluate these patients. Having abdominal pain, Hyperemesis gravidarum vaginal bleed can come with an headache and evaluating for abdominal emergencies and Ruling out Ectopic Pregnancy at the same time deciding about CT Head and Headache work up is a complex issue. They can also have HELP Syndrome or Eclampsia also can start with Headache.

• Age is crucial before Young Female with Headache and Cold and Cough is different from a 50 Year old with Headache and Blurry Vision.
• History taking should include: When did it start, how severe is it from a scale of 1-10, any other symptoms of Dizziness, Focal weakness, Gen weakness, Vision changes, neck pain, Syncope Seizures, Nausea, Vomiting Diarrhea, Chest Pain, SOB, Neck Pain/Stiffness, Dizziness, Vertigo have to be ruled in or ruled out.
• Past History of DM HTN CAD CVA Cancer HIV Hep B Hep C are important. Is patient on anticoagulants also is key history point.

Some Cluster approaches are:

• Fever, Tachycardia, Headache, Neck Pain: Here Headache can be as simple as a Viral Fever or as severe as early meningitis or even a URI if Cold Cough Sinus Tenderness are present.
• Headache could be a early Bleed (Subarachanoid) or even a CVA when patients have vasculitis, Bleeding disorders, Hypertension , DM.
• Headache can be due to Glaucoma or due to Otitis Media or even early Temporal arteritis.
• Headache can be segmental along a nerve for a early developing Zoster.
• Syncope, Fall, Seizure, Loss of Sensorium, Altered Mental Status with Headache all can be indicating a worse diagnosis  than how the Headache presented.
• Post Ictal Phase can present as Headache.
• Another confounder: MI/ACS can also present as an Headache so can arrhythmia or PE. So EKG Trop are Important.

There have been cases who have presented as an Headache and when you do labs there has been Low Hemoglobin and patient has a GI Bleed and the Immediate anemia has caused an headache.

Be very particular and alert when Patients says "Headache is what brought me to the ED". On the other hand there is tons of Literature of approach to Migraine in ED.

Its very important that you read the literature as there are various combinations of medications used to break the migraine. When a patient says "I have a Migraine attack" you still have to approach it as an HEADACHE.

Sometimes patients present with Neck Pain and Stiffness and we disregard it as "Slept on wrong side or Neck sprain". Evaluating for Cord Compression and keeping Dissection and SAH as a differential is equally important as much as ACS/MI or even a Retro pharyngeal abscess in a URI patient.

What it comes down to is:

• Vitals, Past History, Med List, Clinical Co-Symptoms, History of Complaint, Detail Clinical Exam to include total undressing of patient Neuro Vascular HFN HEENT Exam and Lab Results is crucial.
• Overdose and Drug abuse are important historical points which can indicate Cocaine abuse or even overdose unintentionally on paracetamol ibuprofen trying to self medicate with Over Counter Medications.
• CBC, LFT RFT Trop EKG UA Tox Screen and CT / MRI ESR are a part of the work up in ED.
• In a patients with Hypoglycemia or Hyperglycemia Ketoacidosis versus Toxicity v/s sepsis or infection has to be kept at back of mind.
• In HTN emergency headache can be because of raised BP and Raised BP can cause headache. Treating both is important but also is important ruling out cardiac pathologies a CT Head and look for Posterior Reversible Encephalopathy Syndrome.
• I have also read reports where patients were on anticoagulants and had neck pain and when MRI was done it has Hemomyelia into the spinal cord.
• There have been cases alcoholism where patients wake up with headache in ED but they dont know that Methanol or Toxic alcohols were also drunk and they have an Headache.
• Being very aggressive to rule out meningitis and SAH and using Spinal Taps with Clinical Co relation is important in the ED.
• Patients often return post spinal tap with headache and at this time Blood Patch becomes a choice after you have ruled out any other cause or pathology.
• Patients also have headache after Nitro given for Chest Pain.
• Fever can exacerbate Headache and Hunger can do that too.
• A TIA can be presenting as Headache being one of the Co-Symptoms.

Documentation:

• Always Document in detail the history the clinical exam and the plan for ordering tests and meds and chart your thought process and notes as you reevaluate the patient.
• That helps and maintains the continuum of care at the same time maintaining standards of care.
• Discharge is a crucial part. Here too Educating the patient and giving return instructions is key.

Do not Disregard or Less regard HEADACHE. Its a Part of the PAIN PATHOLOGIES which can cause PAIN if ignored.

Patients have Pain , treat it first but work it up and decipher the cause then treat the cause....  FOR THE PATIENTS !

Author: 

                                                   

Dr. Sagar Galwankar  

MBBS, DNB, FACEE (INDIA), MPH, Dip. ABEM (USA), FRCP (UK)

Chief Academic Officer of the INDO-US Emergency and Trauma Collaborative 

Assistant Professor 

Department of Emergency Medicine 

University of Florida, Jacksonville 

(Follow Dr. Galwankar on Twitter @SagarGalwankar)

Sorting out Gabrahat (Anxiety) ~ The Common Complaint in the ED

 Gabrahat (Anxiety) is often a common complaint with many implications.

While working in Emergency Departments in India I have been surprised with what the ultimate diagnosis was when I investigated Gabrahat.

For me Gabrahat is as vague as the Horizon and I take this complaint very seriously. It is very easy for any Nurse or Emergency Physician to get framed and just label Gabrahat as Anxiety or Hysteria.

This can be the Epic Blunder of Large Proportions. 

Many times relatives who accompany the patient will Frame the Emergency Physician by saying words like “There is Tension”. What they mean to imply is Gabarahat is Stress Related.

I often relate Gabrahat to a “SENSE OF IMPENDING DOOM”. When you grade GABRAHAT in that perspective, it guides the Emergency Physician to be very Proactive and diligent.

Let me share a few blasts from the past which I have modified for the sake of Education.

Case One:

Middle Age Female comes to the ED saying that she is feeling SOB. She is hyperventilating and Diaphoretic. She says that she has been having pain all over the body and fells GABRAHAT as if something is going to happen to her.

Her vitals are stable but she continues to breathe hard and breath fast. The relatives were doing a Fine job of Framing her as hysteria.

Rapid Fire Questionnaire Labs EKG Trop and a X-ray Beta HCG UA and a BNP are ordered.

On examining the patient the only Finding is the breathing. Lorazepam given IV and Oxygen started and ABG Ordered which is showing alkalosis. Aspirin given and a bedside Glucose is Normal. She settles down but continues to breathe hard. A CTA Chest is ordered. 

There are massive shower Pulmonary Emboli. Pt gets thrombolyzed and goes to ICU.

Case Two:

A 55-year-old women comes with GABRAHAT. She says that she is afraid something is going to happen. She has no other symptom. She has no Past Psyc Issues.

Labs EKG Trop and an X-ray UA ordered. She has had a prior hysterectomy.

She had an ST Elevation MI. Went to the Cath Lab. No Symptoms at all. No Past History at all.

Case Three:

30-Year-old man came saying He had Gabrahat and felt that there was Irritation in the Chest. NO PAIN BUT ONLY IRRITATION. Exam Past History negative.

Cardiac labs CBC RFT LFT was negative so was his EKG and Xray. Against the will of the Internal Medicine Colleagues Pt admitted. 4 hour repeat EKG and Trop was placed from the ED. His EKG was normal but his Trop had become positive.

Cardiology who scheduled the patient for a cath after admitting him to CCU found a Tight Lcx Lesion which needed a Stent.

Case Four:

48 Female with Gabrahat. Second visit after discharge from the hospital. Come back saying she is afraid. No Pain, No Focus of Infection. 

CBC RFT LFT Cardiac Labs X-ray Beta HCG and UA Negative.

Says her Mind tell her Something is wrong. She has GABRAHAT.

Was admitted in a nursing home. CBC Electrolytes creatinine and SGPT was done and after overnight IV Fluids patients sent home. A CT Head done and the patient had SAH. No Neck stiffness no Eye signs. Admitted to Neurosciences ICU

The only thing that prompted a CT Head was “My Mind is telling Me. This was perceived as Hallucinations hence CT Head Ordered.

Case Five:

18 Year Old Male comes with Gabrahat with Hallucinations. He was at friends party and says “ I have gabrahat as I see a ghost”.

Tox Work up was done and it was positive for multiple substances.

Routine CBC RFT LFT EKG Trop UA and Xray with a CT Head and Tox Screen were done.

Case Six:

40 year old male comes saying that he has Gabrahat and he feels like a huge Log of wood just fell on his head and nailed his whole body vertically into the ground. Clinical Exam and Vitals were normal.

CBC LFT RFT Trop EKG Xray negative

No Neck stiffness Neuro exam normal. He kept saying I am afraid I am sinking into the ground.

CTA Aortagram ordered: He had a dissection from Thorax to iliac bifurcation.

Admitted to CVTS Sx.

Summary:

• Basic Approach should be T/P/R/BP/Pulse Ox
• I always order a CBC LFT RFT EKG Trop CXR. Looking for Rhythm abnormalities is also important. Fever can also cause Gabrahat.
• In Females in the Pregnancy Age group a HCG-UA is ordered
• If Patient has SOB I will R/O Thoracic Causes like Dissection/Pneumothorax and PE.
• If Patient has a presentation of Altered Mental Status I always order a CT Head.
• If Toxicology screen is available, I will order one.
• Co-Symptoms should guide further investigations.
• Discussing with the Relatives in key to educate them- that this is not Hysteria / Tension / Stress. Those are the diagnosis to be considered once Major Life threatening causes are ruled out.
• I have often Seen Marital Discord / Intimate Partner Abuse to be causes of GABRAHAT. So Going deeper into the history. Sitting with the patient with Privacy is the key.
• Anxiety / Panic attack also can be on the differential once Major causes are ruled out.
• Being a Compassionate Emergency Physician is the key. Communication is the answer and Competency to Care is crucial.
• GABRAHAT CAN KILL !

I want to Share a Web Review of what Non EM Experts say about GABRAHAT.

I feel a Well Trained Emergency Physician leaves no stone unturned to do the best for his/her patient

Web Review:

• http://bhj.org.in/journal/special_issue_tb/DPII_11.HTM
• http://hrelate.com/natural-remedies-for-anxiety/
• http://www.njhonline.com/1993/july_aug_93_vol_11_no_4/spider/ghabrahat.shtml

Author:

Dr. Sagar Galwankar

CEO of INDUSEM & Faculty of Emergency Medicine at University of Florida Jacksonville, Florida

@SagarGalwankar

Sagar completed his med school from the University of Pune (India). He attained Board Certified in Internal Medicine from the National Board of Examinations in India. Following this, he went on to train at the University of South Florida, USA in areas of International Health Diplomacy, Infectious Diseases and Emergency Medicine. He also holds a MPH from the University of South Florida and is a Board Certified Emergency Physician with the American Board of Emergency Medicine.

Sagar's academic and clinical career spans over a decade with experience in Education, Care and Research both in India and the USA. He has extensively published, cited and honoured for his works in International Medicine, Public Health, Infectious Diseases, Emergency Medicine and Injury Sciences. Sagar is the Founder and CEO of the INDO-US Academic Initiative for Emergency and Trauma and continue to play a defining role in establishing Emergency Medicine as a separate specialty in India.

He has had previous appointments at the University of South Florida and University of Florida in Departments of Emergency Medicine, Internal Medicine, Global Health and Mental Health. His areas of Interest include Emergency Medical Intelligence, Health Policy, Injury Medicine, International Health, Humanitarian Assistance, Quality Health Care Delivery in Emerging Economies and Global Health Diplomacy.  Sagar believes that "The role of the World's Largest and the Oldest Democracies namely India and United States is crucial for the future progress of transitional Economies and Peace across the Globe". Health is Definately an important part of this growth Story.

Originally published at beepers365.blogspot  on 11 December, 2016. Reposted with permission.