Headache
General Medical Emergencies 975 Refer the patient to the medical team or stroke unit for admission and defini-
tive management.
(i) Give aspirin 300 mg orally daily or via NGT within 48 h, once CT
scan has excluded haemorrhage.
(ii) Avoid the temptation to treat acutely raised blood pressure
unless aortic dissection (see p. 000) or subarachnoid
haemorrhage (see p. 99) are found, or
(iii) In an ischaemic stroke if the BP is acutely raised
220/120 mmHg, when reduction by 10–20% may be performed
(i.e. no lower than 180/100 mmHg initially). Get senior ED
doctor help.
6 Seek an urgent neurosurgical opinion for acute hydrocephalus, or a cerebel-
lar hemisphere haematoma >3 cm presenting with headache, dizziness,
vertigo, truncal or limb ataxia, gaze palsy and a diagnostic CT brain scan.
HEADACHE
DIFFERENTIAL DIAGNOSIS
Consider the serious or life-threatening diagnoses first:
● Meningitis
● Subarachnoid haemorrhage
● Space-occupying lesion
● Temporal arteritis (age >50 years; erythrocyte sedimentation rate [ESR]
50 mm/h)
● Acute narrow-angle glaucoma
● Hypertensive encephalopathy.
The majority, however, will be due to:
● Migraine
● Tension or muscle contraction headache
● Post-traumatic headache
● Disease in other cranial structures.
The history is vital as physical signs may be minimal or lacking, even in the
serious group. A new headache or a change in quality of a usual one must be
evaluated carefully, especially in the elderly.
Meningitis
DIAGNOSIS
1 Causes include meningococcus, Streptococcus pneumoniae, Listeria mono -
cytogenes (adu lts over 50 yea rs, i n a lcohol ism, preg na nc y, i m mu nosuppression
or cancer, and in infants <3 months along with group B streptococcus and