History and thorough physical examination, selective investigations are important in correct diagnosis of acute headache-Tanzeem Haider Raza


 RCP-AZNMC International Medical conference proceedings-VI

History and thorough physical examination, selective
investigations are important in correct diagnosis
of acute headache-Tanzeem Haider Raza

Secondary causes include SAH, ocular disorders, high intracranial
pressure, carotid artery dissection and hypertensive encephalopathy

Lumber Puncture is a must if there is clinical
suspicion of SAH but CT is normal

LAHORE: Dr. Tanzeem Haider Raza Member Council, Royal College of Physicians London spoke about Acute Headache- What to do and when during the International Medical Conference organized by Azra Naheed Medical College in collaboration with Royal College of Physicians London held at Lahore during February 2016.  Referring to the RCP London, he said, it was the oldest institution in the world setting healthcare standards for the institutions. Talking about clinical approach to headache, he discussed at length what not to miss and the diagnostic criteria for primary headaches. He also talked about SAH and its differential diagnosis besides presenting some case histories.

Prof. Arif Siddiqui, Dr. Tanzeem Haider Raza, Prof.Saeed Hamid and
Dr. Peter Trewby chairing a session during the international medical
conference at Lahore organized by ANMC in collaboration with
RCP London during February 2016.

The first case he presented was a 29 years girl who presented with severe headache which had started suddenly three hours earlier frontal as well as occipital. She also complained of nausea and vomited once and light was hurting her eyes. She had recently returned from Africa and had no malarial prophylaxis. She complained of stiffness in the neck, numbness in the legs initially which later resolved.  She felt hot and dizzy on standing. She had no significant past medical history. Headache, he said, is a common problem seen in emergency and it accounts for 2% of hospital admissions. Focal history in such patients, he said, was very important. Neurological examination showed neck movements painful with some stiffness, cranial nerve NAD except painful eye movements and pupils were normal.  One third of these patients, Dr. Tanzeem Haider Raza opined may have a serious underlying cause. The primary objective should be not to miss serious headaches, relieve headache, investigate and plan long term management.

Speaking about clinical approach to headache he highlighted the importance of careful history, thorough physical examination and ordering selective investigations. Primary headache could be due to migraine, cluster headache and tension type headaches. Secondary causes include subarachnoid haemorrhage, ocular disorders, high intracranial pressure, carotid artery dissection, hypertensive encephalopathy and lumber puncture. She had lumbar puncture, CT scan. Opening pressure was high, shunt was inserted and she was discharged on tenth day and was doing well. He pointed out that 1.4% of the patient presenting with headache have SAH and this increases to 12% if only worst headaches are considered and further increases to 25% if there are accompanying abnormal signs. SAH accounts for 8% of all acute CVAs.

Continuing Dr. Tanzeem Haider Raza said that accurate early diagnosis is critical since 25% of patients die within the first twenty four hours. Again 50% of the survivors die due to second bleed. Early surgical intervention reduces complications and improves outcome but misdiagnosis is quite common. Speaking about signs and symptoms of SAH he mentioned sudden severe headache, worst headache of the patient’s life, often provoked by exertion accompanied with vomiting and transient loss of consciousness, neck rigidity, retinal  or subhyaloid haemorrhage, focal neurological signs i.e.  3rd or 6th nerve palsy, nystagmus, aphasia and hemiparesis etc. About 50% of SAH may occur at rest and it can be in any location and may resolve spontaneously. However, they do tend to develop abruptly. Talking about the diagnostic pitfalls he said that pain is not very severe, vomiting and fever may be prominent, pain is mostly in the neck, head injury after a fall, excessive focus on high blood pressure and abnormal ECG. CT can be false negative in case of small bleeds and it might miss up to 20% of SAH. Standard MR is inferior to CT in detecting acute SAH. Lumber Puncture is a must if there is clinical suspicion of SAH but CT is normal. CSF pressure should always be measured. In order to identify the high risk patients he mentioned associated LOC, diplopia, seizure or focal neurological signs,  personal and family history of SAH, polycystic kidney disease, retinal  or subhyaloid haemorrhage, neck rigidity. These patients, he said, should be considered for non-invasive vascular imaging even with negative CT and Lumbar Puncture.

Azra Naheed Medical College in collaboration with Royal College of Physicians London organized an
international medical conference at Lahore in February 2016. Picture taken during the conference shows
some of the presenters from (L to R) Dr. Masood Jawaid, Dr. Moazzam Baig Mirza, Prof. Saeed Hamid,
Prof. Bilal Bin Younis and Dr. Abu Bakar being presented mementoes
on behalf of the organizers.

Summarizing his presentation Dr. Tanzeem Haider Raza said that one should consider SAH in headache which is abrupt and maximum at the onset, first or worst headache of the patient’s life. It is qualitatively different in patients with previous headaches. It is important to look for associated neurological signs, remember common pitfalls and normal CT should be followed by Lumber Puncture. It is also important that who is looking at the CT and who has performed it and on which machine? Properly performed CT and LP can identify vast majority of patients with SAH.

Earlier Dr. David presented a case of Brain Stem Encephalitis and also discussed the differential diagnosis including viral encephalitis. The patient suffered from this disorder four days after arriving from Asia.  The patient had headache, convulsions and respiratory arrest. He then pointed out that poisoning can kill such patients very quickly. This patient in fact died due to heat stroke. She suffered from dehydration, had high work intensity, high temperature and high humidity.  She also suffered from 20% body weight loss. He pointed out that in case of heat stroke, aggressive cooling is utmost important. One must allow adequate time for acclimatization. It may be mentioned here that during 2015, there were over two thousand deaths in Pakistan due to heat stroke.

In the next session Dr. Saulat Siddique talked about new guidelines on management of hypertension. The next presentation was on traumatic brain injury which is a major cause of death and disability in USA. Neuro pathological classification of such injuries was also discussed in detail. Dr. Akhtar Bandesha from PIMS Islamabad spoke about use of FFR in contemporary coronary intervention in the management of IHD.