Troubling headache….

Your first patient of the day is a 46-year-old female with a history of migraine headaches who presents with a severe, constant pain that started suddenly while running. She admits this ?feels different than my normal headaches.? On examination, she appears ill and is vomiting. Her neurologic examination demonstrates mild neck stiffness. She asks for a refill of her sumatriptan, which ?always works for my headaches.? While she has a known primary headache disorder, the features of her headache are concerning.

What do you do next?

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Last Updated on January 26, 2023

28 thoughts on “Troubling headache….

  1. This headache needs to have further studies, CT scan of brain is a must! If no lesion is evident on CT study, a LP has to be done under the suspect of SAH.

    Endotraqueal intubation if GCS is lower than 8 points

    Greeting from Peru

  2. the new headache are different from previous migrain headache and also present of neck stiffness and look ill , all these indicated of life threatening causes of headache , so the patient need further work up, start by brain CT scan if negative follow by LP,

  3. CT and labs. Followed by LP to rule out SAH and meningitis if CT neg. Less likely dx is encephalitis.

  4. CT head w/out contrast initially – if within 6h should be sufficient to R/O SAH. However depend on my clinical suspicion, I would LP regardless and ofcourse if headache started >6h ago and observe.

  5. This history makes a subarachnoid hemorrhage come to mind. My next moves would be a Head CT and if not diagnostic, then a lumbar puncture. We always have to bear in mind that patients can have concomitant conditions – primary headache is the “red herring” that could mislead.

  6. Change in nature of HA, sudden onset and neck stiffness concerning for SAH.
    CT/LP is indicated.
    LP looking for RBC in csf that is not clearing. compare tube 1 to 4.
    consult neurosurg with concerning lp results.
    Treatment, imitrex (worth a shot), antiemetics, analgesics. Most suprizing/concerning is that she is not requesting diluada (kidding).

    question I have done many CT/LPs and the LP has never been positive after. given risk of LP,benefit and alternatives unless it is a concerning sudden onset case like this should we really consider ct/lp the standard of care. based on my experience I don’t believe so. In fact, I think we may be forced to do excessive LPs and given the risks/discomfort/resource usage (LPs and results take a while) the risks of standard of care ct/lp is inappropriate. That would be the equivalent of every troponin we order must be followed by a stress test. thoughts???

  7. Do a CT scan then LP to rule out brsin hemorrhage (ruptured sneurysm, hypertensive bleed) and CNS infections (meningitis, meningoencephalitis)

  8. it seems a SHA , BROKEN ANEURYSM ,
    do a CT, neuroprotection , if ct normal lumbar punction .
    best regards

  9. change of headache character and its prolongation with stiff neck and not responding to usual medications need Fundoscopy +Brain CT scan in the ER,If clear fundoscopy and CT scan maybe she will need for LP to exculde xantochromia ,urgent follow up with neurologist .

  10. CT brain with out contrast, CMC, CMP, U Preg, UA, PT-INR/PTT –LP if ct is negative

    1. SAH
    2. concider menengitis

  11. I would do CT because vomiting can be the sign of elevated intracranial pressure (in anamnesis there is sudden pain while running) LP without CT can be dangerous.

  12. Absolutely needs further evaluation. Non-contrast CT brain to evaluate for SAH followed by LP if negative.

  13. the history have some concerning notes:
    – sudden onset
    – during physical exercise
    – different from previous episodes
    – neck stiffness

    a brain ct w/o contrast is the first and if shows nothing LP is indicated

  14. I would perform a brain simple TAC to search any bleeding, because she have a change of the pattern of headache, and starts with excercise; if the TAC is normal, eve I could perform a contrasted RM, because the probability of a cns venous thrombosis.

  15. For those of us considering meningitis. Why, what percent of pts with meningitis have “sudden onset” HA??

    I would think that tapping someone w/o a sudden onset HA for meningitis would have significant worse risk of complications than truly finding a meningitis. would you also emergently start the pt on antibiotics?? steroids???

    There is no description of the duration of the pain thus unless greater than 12hours xanthocromia would not be demonstrated. In my N of 1 experience with CT neg then LP concerning of SAH when neurosurg is consulted unless the neuro exam is abnormal they demand a CT angio not believing the results of the tap.

    SAH – Management, ABCs, blood pressure control, monitor plt/coags, neuro checks, CCB to control for vasospasms, pain control. icu admit

    What is a brain simple TAC? Thanks

  16. Do CT. If CT done within 6 hours and the CT was done with modern scanner and can be read by experienced radiologist no LP needed. This in view of recent literature: BMJ 2011; 343: d4277

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