0071643192.pdf

NEUROLOGY

■ Steroids: Controversial; may work in refractory migraines

■ Opiates should be used as last resort.

■ Prophylactic therapy may be indicated in patients with frequent migraines:

β-blockers, Ca++channel blockers, tricyclic antidepressants.

Tension-Type Headaches

PATHOPHYSIOLOGY

Thought to share a common pathophysiology with migraines

SYMPTOMS

■ Bilateral, nonpulsating, not worsened by exertion

■ Usually not associated with nausea and vomiting

DIFFERENTIAL

■ Other primary or secondary headaches

TREATMENT

■ NSAIDs

■ For severe headache →treat same as migraine.

Cluster Headaches

Cluster headaches are most common in young to middle-aged men and may

be precipitated by alcohol and stress. They result from dysfunction of the

trigeminal nerve.

SYMPTOMS/EXAM

■ Severe, unilateral orbital, supraorbital or temporal pain

■ Episodes last for 15–180 minutes, but recur in clusters (eg, daily on same

side for weeks).

■ Associated ipsilateral findings:

■ Conjunctival injection, lacrimation, nasal congestion, rhinorrhea, facial

swelling, miosis or ptosis

TREATMENT

■ High-flow O 2 is effective in 70% of patients.

■ IV dihydroergotamine or sumatriptan; oral preparations take too long to be

effective

■ Prophylaxis with oral steroid burst, verapamil, or antiepileptic agents

A 58-year-old male is brought to the ED by his daughter for change in

mental status. He was last seen 2 days earlier at work and was normal.

Today he is disheveled, disoriented, and appears to be hallucinating. His

daughter says the symptoms have been waxing and waning. You have trouble

maintaining his attention during the examination, and you note a fine tremor.

What is the most appropriate treatment for this patient?

This patient clinically has delirium. Treatment is aimed at the underlying cause.