Troubling headache…. May 30, 2012

Posted by Andy Jagoda, MD in: Neurologic, Radiology , trackback

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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1. The latest What’s Your Diagnosis… « What's Your Diagnosis? - May 30, 2012

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2. Christopher Uriarte Landaeta - May 30, 2012

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

3. Mona jawish - May 30, 2012

this patient need urgent brain ct- scan if ABCs are stable

4. Omar farid - May 31, 2012

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,

5. Alex Bobrov - June 1, 2012

CT/LP as mentioned above. Sounds like a ruptured berry with a SAH

6. Matt Frankel - June 1, 2012

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

7. Dave - June 1, 2012

CT/LP. Be sure to get an opening pressure on the LP as well if there is no visible blood.

8. Fasika - June 1, 2012

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.

9. Maria Tolete - June 1, 2012

CT is a must, looks like ruptured aneurysm.

10. Alan L. Sisson, MD, RPh - June 1, 2012

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.

11. Ajeet Dube - June 1, 2012

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???

12. tina achacoso - June 1, 2012

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

13. suresh naidu - June 2, 2012

agreed with above comments….ct scan tro SAH …LP if needed. ABC as in any other case

14. Lilian - June 2, 2012

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

15. Adel Noman - June 3, 2012

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 .

16. Lois -Ann Welsh - June 3, 2012

CT then LP, r/o meningitis

17. Debra Dibartolo - June 3, 2012

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

1. SAH
2. concider menengitis

18. dr Anda Piebalga - June 4, 2012

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.

19. Nicolas PESCHANSKI, MD - June 4, 2012

Head CT W/O contrast first (within 6 hours of onset)… SHA first coming in mind. Then, LP with biology. Keep in ICU for a while and isolated room regarding the possibility of meningitis.

20. le - June 4, 2012

leaking aneurysm

21. le - June 4, 2012

leaking cerebral aneurysm

22. marathonmedic - June 4, 2012

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

23. AATHURA - June 5, 2012


24. hamid R. - June 5, 2012

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

25. Fernando Cardona steadysword - June 6, 2012

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.

26. Ajeet Dube - June 6, 2012

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

27. Dimitri - June 7, 2012

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

28. karthik - June 9, 2012


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