HTN + Headache

[herewego]

What do you guys do for people with elevated BPs, say...200+/100+ who complain of headache, but no neurological deficits by history or exam? CT head? Just treat the headache? Is this symptomatic hypertension?

I've had some attendings not scan the head, just treat the head, hope the BP comes down afterwards. I guess I'm a little confused because if someone came in with a BP of 200+/100+ and said "chest pain" or "Sob" that usually buys them a cardiac workup for end organ damage.
I guess the argument could be made that you don't have a great physical exam finding for myocardium death, but someone with a bleed would likely have some sort of physical exam findings..

Thoughts?

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[msgsk]

There's no clear answer - it really depends on the patient ie how do they look, how have their blood pressure's been in the past, and have they felt similar headaches whenever their pressure has gotten high? The real world answer, which may be different from the evidence-based answer, is in most cases I do the scan. Unless the patient is adamant that this is normal for them, from a medico-legal perspective if systolic is > 200 and they have a headache, I'm going to CT.

 

[fahimaz7]

I had one rupture their unknown aneurysm (H&H 5 SAH) in front of me the other day after a negative CT and LP. Scary stuff. Not that I'm going to change my practice regarding HTN and headaches (presented @ 200/100. Came down to 150/80's after 1st round of migraine management), but sure does make you think about some stuff.

 

[Birdstrike]

I had one rupture their unknown aneurysm (H&H 5 SAH) in front of me the other day after a negative CT and LP. Scary stuff. Not that I'm going to change my practice regarding HTN and headaches (presented @ 200/100. Came down to 150/80's after 1st round of migraine management), but sure does make you think about some stuff.

After CT and LP? Oh geez. Of course. Smh

 

[Birdstrike]

What do you guys do for people with elevated BPs, say...200+/100+ who complain of headache, but no neurological deficits by history or exam? CT head? Just treat the headache? Is this symptomatic hypertension?

I've had some attendings not scan the head, just treat the head, hope the BP comes down afterwards. I guess I'm a little confused because if someone came in with a BP of 200+/100+ and said "chest pain" or "Sob" that usually buys them a cardiac workup for end organ damage.
I guess the argument could be made that you don't have a great physical exam finding for myocardium death, but someone with a bleed would likely have some sort of physical exam findings..

Thoughts?

It all comes down to this: Do you think the person is having a hemorrhagic stroke or not, either SAH or parenchymal bleed?

Yes or no?

If the answer is, "No" then you don't need a CT or any other special work up beyond controlling BP.

If the answer is either, "Yes" or "Maybe" then you need to prove to yourself they're not.

Ischemic strokes generally don't cause headache (it can happen, I've seen it, but it's not typical) so it's rare for headache to be a harbinger or early sign of an ischemic CVA. This is the drastic difference between CP and HTN where pain or discomfort can be an early sign of impending disaster.

Most "headache and HTN" turnout to be nothing serious. It comes down "bleed or not?" And if there are other signs of stroke or not. If so, that's an easy and obvious CVA work up.

HTN + headache does not equal "stroke until proven otherwise," as you are obviously aware.

Just ask yourself: Am I worried about a bleed? If so, what's the likelihood of a cranial hemorrhage with no other signs?

It's not always easy. When in doubt: Work. It. Up. (Although I'm sure someone will disagree and say God kills a baby kitten every time you order a test that turns out negative). The longer you practice the less you'll move in doubt. But like most other things, these work ups are usually negative without some other clue, but not always. That's the kicker. Not always.

You know what? Forget what I just said. Call a doctor. Oh, wait.....That's you.

 

[Apollyon]

Ischemic strokes generally don't cause headache (it can happen, I've seen it, but it's not typical) so it's rare for headache to be a harbinger or early sign of an ischemic CVA.

I just mention this because, coincidentally, I had a 27 y/o yesterday who had an ischemic CVA, who had a headache right in the area of the infarct.

 

[Birdstrike]

I just mention this because, coincidentally, I had a 27 y/o yesterday who had an ischemic CVA, who had a headache right in the area of the infarct.

Lol. I know. I learned that the hard way, too. Which is why I hedged with "generally" and "can happen." So many patients don't read the book before they decide to get sick. It's a crazy job, being a doctor.

 

[dotcb]

I separate them as 2 problems:

HA - usual questions - Hx of HA, Onset, neuro/visual sxs, etc. Decide whether to do CT and LP, treat the HA.

BP - Do I think there is end organ dysfunction? Does the BP need any testing to be done? Often not. Make sure the pt has taken their home HTN med PO.

Dispo accordingly. I always tell trainees - Patients worry about high BP, nurses worry about HTN. As an emergency doctor, you should very rarely worry about hypertension.

 

[Nebero]

When nurses worry about asymptomatic elevated BP, the treatment is Ativan 1mg Q2 hrs until symptoms resolve.



For the nurse.

Sent from my SCH-I535 using Tapatalk

 

[Doctor Bob]

When nurses worry about asymptomatic elevated BP, the treatment is Ativan 1mg Q2 hrs until symptoms resolve.



For the nurse.

I had to transfer a pt from my ED to another facility. The pt hadn't seen a doc in 2 years; comes in asymptomatic with a SBP of 200 (well.. asymptomatic as it related to the BP). I was gave her a little hydral which got her to an SBP of 180. But the nurses on the floor at the receiving facility refused to take the pt unless we brought her BP down. Despite a discussion about the tx of asymptomatic HTN, they continued to refuse. Eventually the transfer occurred. Come to find out when the pt hit the floor there, the nurses browbeat the residents into giving her more meds for her BP because they didn't "feel comfortable with her having a BP that high; she might have a stroke". The next note I read in the computer is that the pt has an SBP of 120 and is getting evaluated by MICU for ? neuro deficits.

 

[xaelia]

Usually, headache begets elevated BP, not the other way around (usually).

It's almost always appropriate to just treat the headache and counsel the patient on the long-term risks of uncontrolled hypertension.

There are atypical presentations of all manner of diseases, and when the clinical picture is off, do something different.

Asymptomatic hypertension is managed in keeping with the natural course of the disease: "It took a long time for your body to develop and become used to these extremely elevated blood pressures; we're going to slowly bring your blood pressure into better control in a stepwise fashion over the next several (days, weeks, depending on your system)."

 

[southerndoc]

After CT and LP? Oh geez. Of course. Smh

Reduced intracranial pressure from the spinal CSF leak caused stretching of the arteries which led to rupture of the aneurysm?

If they have a normal neurologic exam, I don't scan them (unless they're really in agonizing pain). If they need admission for some reason, then our hospitalists won't admit them without a head CT, so then I have to order it.

 

[Birdstrike]

Reduced intracranial pressure from the spinal CSF leak caused stretching of the arteries which led to rupture of the aneurysm?

If they have a normal neurologic exam, I don't scan them (unless they're really in agonizing pain). If they need admission for some reason, then our hospitalists won't admit them without a head CT, so then I have to order it.

Wow. You should be a plaintiffs attorney. Yikes

 

[Arcan57]

If you routinely discharge HA + HTN without a work-up, at some point in your career you're going to send home an ICH. If you routinely work-up every HA + HTN pt then you're going to harm dozens of patients due to complications from the work-up and waste hundreds of thousands of dollars.

Unfortunately this is one of those issues where you have to be a doctor and make a defensible decision with which you and the patient are comfortable. Gradual onset HA without vomiting or neuro signs or migraine HA with usual signs/symptoms gets migraine cocktail and OTD. Anything feels hinky and they get CT to r/o ICH and I have a discussion regarding risks of undiagnosed SAH with the patient. I don't think I have a flawless system but it's reasonable and hasn't landed me in peer review, yet.

 

[herewego]

Appreciate the replies everyone. Feel a little more comfortable managing these situations.

 

[Exanogen]

So I had a female in her 40's, hx of HTN complaining of headache for a few days - Her BP was 170/80 in triage. She saw her PMD a few days ago and increased her lisinopril. No neurological deficits, headache was improved with BP meds in the ER. Her CTB was negative, but her CTA Head showed an aneurysm. Neurosx wanted LP which was positive - she was emergently coiled.

First positive in many years of HTN headaches, hasn't really changed my practice but I usually CTB/LP most of these patients (or offer LP that is)

 

[cbrons]

I just mention this because, coincidentally, I had a 27 y/o yesterday who had an ischemic CVA, who had a headache right in the area of the infarct.

How/why

 

[cbrons]

I had to transfer a pt from my ED to another facility. The pt hadn't seen a doc in 2 years; comes in asymptomatic with a SBP of 200 (well.. asymptomatic as it related to the BP). I was gave her a little hydral which got her to an SBP of 180. But the nurses on the floor at the receiving facility refused to take the pt unless we brought her BP down. Despite a discussion about the tx of asymptomatic HTN, they continued to refuse. Eventually the transfer occurred. Come to find out when the pt hit the floor there, the nurses browbeat the residents into giving her more meds for her BP because they didn't "feel comfortable with her having a BP that high; she might have a stroke". The next note I read in the computer is that the pt has an SBP of 120 and is getting evaluated by MICU for ? neuro deficits.

Forgive me, just a novice, but if someone is walking around with a SBP of 180 to 200 for YEARS, havent they already compensated? Their cerebral perfusion pressure at that point likely depends on it being that high, and aggressively treating it right away seems much more likely to cause serious problems.

 

[Doctor Bob]

Forgive me, just a novice, but if someone is walking around with a SBP of 180 to 200 for YEARS, havent they already compensated? Their cerebral perfusion pressure at that point likely depends on it being that high, and aggressively treating it right away seems much more likely to cause serious problems.

You are correct.

 

[Apollyon]

How/why

R ICA, don't know why. Only R/F was tobacco use (and snuff, at that - not cigarettes). MRI confirmed.

 

[TooMuchResearch]

Forgive me, just a novice, but if someone is walking around with a SBP of 180 to 200 for YEARS, havent they already compensated? Their cerebral perfusion pressure at that point likely depends on it being that high, and aggressively treating it right away seems much more likely to cause serious problems.

Absolutely. That's why the aortic dissection patients develop the old encephalopathy when their BP is aggressively dropped from 200 systolic to 90.

 

[BoardingDoc]

I had one rupture their unknown aneurysm (H&H 5 SAH) in front of me the other day after a negative CT and LP. Scary stuff. Not that I'm going to change my practice regarding HTN and headaches (presented @ 200/100. Came down to 150/80's after 1st round of migraine management), but sure does make you think about some stuff.

How the hell did that one play out? New obvious neuro deficit? Just a sudden worsening HA? Did you scan them again?

 

[southerndoc]

R ICA, don't know why. Only R/F was tobacco use (and snuff, at that - not cigarettes). MRI confirmed.

It happens. I work at a comprehensive stroke center, and I've seen a 17 year old who had an ischemic stroke. Youngest I've heard was a 14 year old in atrial fib.

I'm surprised at the number of ischemic strokes who complain of a headache.

 

[engineeredout]

So I had a female in her 40's, hx of HTN complaining of headache for a few days - Her BP was 170/80 in triage. She saw her PMD a few days ago and increased her lisinopril. No neurological deficits, headache was improved with BP meds in the ER. Her CTB was negative, but her CTA Head showed an aneurysm. Neurosx wanted LP which was positive - she was emergently coiled.

First positive in many years of HTN headaches, hasn't really changed my practice but I usually CTB/LP most of these patients (or offer LP that is)

Aneurysm may not have been related to the headache at all, just an incidental finding that once you guys found, you were stuck dealing with.

Agreed that (acute) hypertension more often than not is a nursing issue rather than an emergent medical issue, the exceptions I can think of being flash pulmonary edema or dissection as mentioned above. The vast majority of patients whose ESI ends up getting elevated solely due to BP have likely been sitting at that pressure for a long, long time. I usually discuss it with the patient and document that we went over risks and benefits of uncontrolled htn and they need to see their primary. Rarely I'll start a low dose something.

Dealing with incidental BP being elevated in the ED is secondary in annoyance to asymptomatic hyperglycemia. Why the triage people have to check a friggen Accucheck on someone because they're a diabetic, despite their CC being ankle sprain, is beyond me. End up with a BG of 400, so I'm stuck getting a BMP, B-HB, and treating with an arbitrary amount of insulin to verify that their sugar is capable of dropping. All this despite the fact that their a1c is probably 14% and BG of 250 is probably hypoglycemic for them.

/rant

 

[Instatewaiter]

Absolutely. That's why the aortic dissection patients develop the old encephalopathy when their BP is aggressively dropped from 200 systolic to 90.

Having stabilized scores in an ICU (perhaps 50-100 in the last few years at a large CTS referral center), I have yet to see anyone develop encephalopathy from dropping their pressure with the approriate treatment. Plus, without dropping their dP/dt they have a 1% mortality per hour. I have seen more than a few of them rupture and die in front of me prior to being able to brought to surgery.

The severe hypertension in type A dissections is usually not old but mitigated by the catecholamine surge from tearing their aorta which is why it takes such a volume of beta blockade to drop the HR to appropriate levels. So you can usually drop the HR and BP very quickly.

 

[austintr]

R ICA, don't know why. Only R/F was tobacco use (and snuff, at that - not cigarettes). MRI confirmed.

As a 27 y/o currently enjoying some Copenhagen Southern Blend and a "normal" BP of 130/80, this is a touch disheartening. At least I'm not morbidly obese, I guess.

 

[TooMuchResearch]

Having stabilized scores in an ICU (perhaps 50-100 in the last few years at a large CTS referral center), I have yet to see anyone develop encephalopathy from dropping their pressure with the approriate treatment. Plus, without dropping their dP/dt they have a 1% mortality per hour. I have seen more than a few of them rupture and die in front of me prior to being able to brought to surgery.

The severe hypertension in type A dissections is usually not old but mitigated by the catecholamine surge from tearing their aorta which is why it takes such a volume of beta blockade to drop the HR to appropriate levels. So you can usually drop the HR and BP very quickly.

I've only seen 3 in the past year, 2 got weird (both type B...the A was already quite stroked out from the dissection).

I definitely would not advocate for not aggressively dropping the rate and pressure.

 

[Instatewaiter]

I've only seen 3 in the past year, 2 got weird (both type B...the A was already quite stroked out from the dissection).

I definitely would not advocate for not aggressively dropping the rate and pressure.

Agreed.

 

[shookwell]

I had to transfer a pt from my ED to another facility. The pt hadn't seen a doc in 2 years; comes in asymptomatic with a SBP of 200 (well.. asymptomatic as it related to the BP). I was gave her a little hydral which got her to an SBP of 180. But the nurses on the floor at the receiving facility refused to take the pt unless we brought her BP down. Despite a discussion about the tx of asymptomatic HTN, they continued to refuse. Eventually the transfer occurred. Come to find out when the pt hit the floor there, the nurses browbeat the residents into giving her more meds for her BP because they didn't "feel comfortable with her having a BP that high; she might have a stroke". The next note I read in the computer is that the pt has an SBP of 120 and is getting evaluated by MICU for ? neuro deficits.

Did she have a reason for admission other than her BP? Because asymptomatic BP of 200 gets a prescription and discharge papers from me.

 

[southerndoc]

Did she have a reason for admission other than her BP? Because asymptomatic BP of 200 gets a prescription and discharge papers from me.

Same here, and every time it requires a discussion with the nurses why asymptomatic HTN without end-organ damage can go home with a prescription.

 

[Doctor Bob]

Did she have a reason for admission other than her BP? Because asymptomatic BP of 200 gets a prescription and discharge papers from me.

Yea; she had newly diagnosed metastatic ovarian CA; the ascites was causing a little gastric compression and making her persistently nauseated. No primary care doc, so I admitted her to facilitate getting plugged in with onc.

Same here, and every time it requires a discussion with the nurses why asymptomatic HTN without end-organ damage can go home with a prescription.

What gets me a lot (from the ICU side) is when I get an admission from the ED because the floor refused them simply due to vital signs. "Sorry, the floor can't take a patient with a heartrate of 120" or "the nurses don't feel comfortable with a blood pressure of 180." And the patient shows up looking just fine.

 

[Arcan57]

Yea; she had newly diagnosed metastatic ovarian CA; the ascites was causing a little gastric compression and making her persistently nauseated. No primary care doc, so I admitted her to facilitate getting plugged in with onc.



What gets me a lot (from the ICU side) is when I get an admission from the ED because the floor refused them simply due to vital signs. "Sorry, the floor can't take a patient with a heartrate of 120" or "the nurses don't feel comfortable with a blood pressure of 180." And the patient shows up looking just fine.

Nobody (only slightly hyperbolic) on the hospital side of things care what a patient looks like. They only care what the patient's chart looks like.

 

[Birdstrike]

Nobody (only slightly hyperbolic) on the hospital side of things care what a patient looks like. They only care what the patient's chart looks like.

True. And there are reasons for this.

In defense of nurses, they're very protocol driven as a profession and don't reward their own for venturing outside protocols, and instead punish those who do.

In other word, a nurse who lets an outlier patient slip through in the interest of efficiency or due to critical thinking, will seldom be praised or rewarded for thinking outside the box or promoting efficiency even if correct, but sure as hell will get slammed down on hard, if a patient's HR is 5 beats out of the protocol's acceptable range and a bad outcome occurs.

So, ultimately, it's generally pointless to blame or resent a nurse for following their protocols, no matter how inappropriate for certain situations. Maybe blame the administrators who set up the system and the protocols, but don't blame or resent a nurse who has smartly adapted nursing survival skills. They know it's better to follow a protocol that may be misguided and fall back on, "I was just following orders," than to be right in breaking a boneheaded rule and lose their job in the process.

 

[Apollyon]

As a 27 y/o currently enjoying some Copenhagen Southern Blend and a "normal" BP of 130/80, this is a touch disheartening. At least I'm not morbidly obese, I guess.

This guys is skinny, too. Not a fatty, and a blue collar guy.

 

[fahimaz7]

How the hell did that one play out? New obvious neuro deficit? Just a sudden worsening HA? Did you scan them again?

She said her head felt funny, then went blue and unresponsive. Intubated. Repeat CT scan in < 10 mins from change. Brain dead the next day after a trip to the angio suite for pipline and EVD.

 

[Docinthetrenches]

It's very simple. You treat the symptoms not the blood pressure. If you think it is a migraine, treat with reglan or whatever and then when they feel better, repeat the BP. I guarantee it will be lower. If still really high and the patient does not have a history of HTN, consider starting PO meds, but NEVER give clonidine (unless the pt is normally on it and missed doses) or nitro or IV stuff to lower BP acutely in these situations. It's just plain wrong and potentially dangerous. The ONLY times to rapidly lower BP are in Aortic Dissection, Hypertensive encephalopathy (or in the case of a pheo, etc), acute renal failure with red cell casts in the urine, and MAYBE acute MI or Acute haemorrhagic stroke (and even in those cases it should be a modest reduction only).

If you think the pt has an SAH, work that up but don't concern yourself with the blood pressure. If there is an SAH, you can give Nimotidpine but that's not specifically to lower the blood pressure.