CRACKCast E020 – Headaches

In CRACKCast, Featured, Podcast by Adam Thomas3 Comments

This episode of CRACKCast covers Chapters 20 of Rosen’s Emergency Medicine, Headaches. This episode reviews the common and life threatening causes of headaches, and dives into red flags you cannot miss when assessing these patients on your next shift.

Shownotes – PDF Here


Rosen’s in Perspective:


  • 90% of people in the US have headaches
  • most patients visiting ED have benign headaches:
    • Tension – 50%
    • NYD – 30%
    • Migraine – 10%
    • Secondary headache – 8%

<1% of those with secondary headaches have life threatening causes


  • ***the brain parenchyma is insensitive to pain***
  • The pain sensitive areas:
    • Meninges
    • Blood vessels
    • Tissues lining the cavities within the skull
      • *this leads to inaccurate localization of pain
    • **most of the pain associated with h/a is mediated through Cranial Nerve V
      • this is then transferred back to the nucleus and then radiated throughout the various branches of the 5th cranial nerve
      • if a specific superficial structure in the head is affected (temporal artery or sinus) then the pain can be better localized
    • ***headache and neck pain should be thought of as overlapping units***

1) List 7 life threatening causes of headaches

  1. Subarachnoid Hemorrhage
  • Up to 20-50% are missed on the first visit to physician
  1. Meningitis
  2. CO poisoning
  3. Temporal arteritis
  4. Acute angle closure glaucoma
  5. Intracerebral hemorrhage
  6. Cerebral venous sinus thrombosis
CO poisoningInfection

Meningitis, encephalitis, brain abscess

Temporal arteritis Acute angle closure glaucomaIncreased



-shunt failure

Cerebral venous sinus thrombosisIntracranial hemorrhage
Enclosed/confined spacesHistory of sinus or ear infectionAge >50


New, atypical headacheHx of benign intracranial hypertension


Sinus infectionSAH:sudden, severe

-hx of SAH or aneurysm

-hx of polycystic kidney disease

HTN: previous vascular lesions

-young or middle aged

Multiple family members with similar symptomsRecent surgery


Hx of collagen vascular diseasesAge > 30

Hx of prev. Glaucoma

CSF or VP shuntHypercoagulable statesSubdural: hx of alcoholism

-use of anticoagulants

Cool seasons, or nearby machinery / equipmentExtremes of age and debilitation

Close living conditions (military, college)

Lack of immunizations




-parasitic or fungal infection

Pain increasing in a dark environment , red eye, large pupil, hazy corneaCongenital or skull abnormalitiesPost partum or peri-partumEpidural hematoma

-traumatic injury

-Lucid→ somnolent


According to Rosen’s:

  • “The most common and consequential mistake made by ERP’s: is thinking that a single CT head clears the patient of the possibility of a SAH or other intracranial disease”
    • Brain CT can miss 6-8% of patients with a SAH (esp. The minor GRADE 1 class)
  • CT sensitivity for SAH (
    • Decreases by 10% for symptom onset > 12 hrs
    • Decreases by 20% at 3-5 days onset of symptoms

2) List 9 red flags on history for headaches

Nine “worrisome” features of a headache:

  1. Sudden onset
  2. “Worst ever headache” or “have never had a headache like this one”
  3. Refractory symptoms despite treatment
  4. Headache onset during exertion
  5. Hx of HIV or immunocompromised
  6. Altered mental status + headache
  7. Meningismus
  8. Unexplained fever
  9. Focal neurological findings

3) When should you perform a CT before performing a LP?

Generally CT should precede LP when investigating headaches…

LP should NOT delay antibiotic administration

  • LP can proceed CT in meningitis if the patient has a normal neurological exam and has no papilledema.

4) Describe 8 clinical findings suggestive of increased ICP

  1. Persistent vomiting
  2. Altered mental status
  3. Hypertension and bradycardia
  4. Bulging fontanelle
  5. Diffuse, severe headache
  6. Loss of venous pulsations in the eye
  7. Optic disc/papilledema
  8. Headache worse when lying down and worse in the morning



1) Describe 5 CT findings suggestive of ↑ ICP (realizing the CT shows evidence of ‘brain shift’, an indirect sign of ↑ ICP).

  1. Loss of the basilar cisterns
  2. Effaced sulci (gyri pushed together)
  3. Decreased ventricular size (ventricular effacement)
  4. Midline shift
  5. Loss of grey-white differentiation

See radiology master class for tutorials on the acute brain and brain anatomy.


2) List 7 non-life threatening causes of headaches

  1. Tension headache
  2. Cluster headache
  3. Cervical muscle strain
  4. Migraine
  5. Post-lumbar puncture headache
  6. TMJ disease / dental disease
  7. Effort-dependent / coital headaches

These shownotes were edited and uploaded by Ross Prager (@ross_prager)

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..