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With this complaint, it’s ALL about doing a good history and exam.

Step 1: Write Out Your Differential Diagnosis

  • The KING
    • Subarachnoid hemorrhage
  • The QUEEN
    • Meningitis
  • 3 Killers in the BRAIN
    • Stroke
    • Hematomas
    • Elevated ICP/Tumors
  • 3 Killers in the VESSELS
    • Arterial dissection
    • Brain DVT (Dural Venous Sinus Thrombosis)
    • Giant cell/temporal arteritis
  • 3 MISCELLANEOUS killers
    • Preeclampsia
    • Carbon monoxide toxicity
    • Glaucoma

Step 2: How Does This Compare to Previous Headaches?

  • Finding the answer to this question is not always easy!

Step 3: Do a FULL Neuro Exam

  • Mental status
  • Neck stiffness
  • Extra-ocular movements
  • Visual fields
  • Cranial nerves
  • Speech
  • Motor
  • Sensation
  • Finger to Nose
  • Gait

Step 4: Order Tests As Necessary

  • CT head without contrast
  • MRI brain
  • Lumbar puncture
  • ESR
  • Carbon monoxide level

Step 5: Give “Headache Cocktail”

  • Mix and match based on personal and patient preferences
    • IV Dopamine antagonist
    • IV Antihistamine
    • IV Steroid
    • IV NSAIDS
    • IV Fluids
    • Tylenol
  • Triptans and opiates rarely indicated

Additional Reading