Hx:
- Onset: 4 days ago
- Context during onset: non-exertional
- History of trauma at any time surrounding onset of headache: No
- Time from onset to maximal severity:
- Previous treatment trying: Tylenol
- Rectal severity per patient: 10/10
- History of headaches in the past: Yes patient states she’s had headaches approximately every month for the past 9 months.
- History of prior headaches: Patient states that for the past 9 months.
- Frequency of headaches at baseline: I every month
- Quality of headache: Throbbing
- Region of headache: Left occipital region
- Associated symptoms:
- Neurological symptoms: blurred vision, no numbness or new weakness in any extremities.
- Ocular symptoms:
- Nausea/vomiting: Nausea but no vomiting
- Fevers/chills: None
- Not on blood thinners:
- No history of intracranial injury in past or intracranial operative interventions or known aneurysms.
- No hx of immunocompression.
Suspect headache of benign etiology.
Patient is non-toxic given history and examination.
No red flags for headache, hence further work up not indicated and patient appropriate for continued outpatient management.
Specifically:
_Doubt meningitis given no neck stiffness, afebrile, well appearing, no altered mental status.
_Doubt acute traumatic intracranial injury given no hx consistent with severe mechanism, benign nuero exam (as above).
_Doubt acute cerebral vascular accident given benign neuro exam (as above).
No red flags for headache, hence further work up not indicated and patient appropriate for continued outpatient management.
Specifically:
_Doubt meningitis given no neck stiffness, afebrile, well appearing, no altered mental status.
_Doubt acute traumatic intracranial injury given no hx consistent with severe mechanism, benign nuero exam (as above).
_Doubt acute cerebral vascular accident given benign neuro exam (as above).
_Doubt intracranial mass given benign neuro exam, headaches NOT worse in morning.
ED COURSE/MDM/A/P:
No clinical features suggestive of a more malignant secondary HA process (no “Red Flags”).
Specifically:
no abrupt onset HA
no first/worse HA (esp in 5>age>50)
not triggered by exertion/sex/valsalva
no change in HA pattern
no new HA in immunocompromised or cancer patient
no HA in preg/post partum
no ALOC/AMS
no neuro sx >1 hr
no abnromal neuro exam
not on anticoagulation/steroids
DIAGNOSTICALLY:
_upreg
_ CT head
_ CBC: non-remarkable and non-conributatory to pt’s condition
_ BMP: non-remarkable (no significant electrolyte derangements)
_ no poorly controlled DM
Interpretation: Basic labs normal, not suggestive of more malignant process and non-revealing of alternative malignant diagnosis causative to patient’s condition.
THERAPEUTICALLY:
-compazine (prochlorperazine) 10mg IV
-beandryl 25mg IV
-IVF 1L NS
-zofran 4mg IV
-ketorolac
-dexamethasome (reduce short term recurrence) 10mg IV/IM
_reglan (metaclopramide 10mg IV/IM)
MDM/ED COURSE/Ddx/A/P:
Suspect cephalagia, primary HA (migraine v tension).
_ >3 POUND criteria (pounding, hOurs 4-72, unilateral, nausea, disabling intensity)
On re-evaluation:
Patient states HA significantly improved, repeat neuro exam intact, pt states feels ready to go home.
WORKING DIAGNOSIS: primary headache
PLAN: Advised for prompt f/u with PCP and neurologist. Return precautions d/w pt including: worsening of HA, decreased strength/sensation, vision changes, somnolence, confusion, fever, lack of improvement.
-ibuprofen/acetaminophen PO PRN
DISPOSITION: home
DDx:
Doubt ICH/SAH given hx (no thunderclap onset, onset not exertional, not worse HA of life/different from prior, no LOC, no neuro deficits)
_ CT (formal read by radiologist) within 6 hours of onset (high sensitivity and d/w risks/benefits of LP w/ pt and elected to defer LP)
Doubt mass given no hx of active cancer, HA not worse in morning, no neuro deficits
_ CT shows no mass.
Doubt encephalitis/meningitis afebrile, no meningismus, well appearing, no AMS
Doubt head trauma given no hx of head trauma and atraumatic head on exam. Doubt cerebral artery dissection given no recent neck trauma.
Doubt cerebral venous thrombosis (CVT) given no risk factors for thromboemnolism, no ALOC, no seizures, no neuro deficits.
_ d dimer (normal suggests very unlikely CVT)
_ normal CT (albeit w/o high sensitivity, with low pre-test probability makes CVT unlikely)
_ CT venography (95% sensitive) v MRI
_
Doubt temporal arteritis given age not > 50, not new onset localized HA, no temporal artery tenderness
_ ESR not >50.
Doubt CO poisoning given no hx concerning for CO exposure
_carboxyhehglobin level
Doubt depression given pt’s affect not depression, pt not exhibiting seeking behavior, pt expresses satisfaction with improvement of symptoms in ED.
Doubt acute obstructive process to CSF given improvement of sx, no nuero deficits, no signs of increased intracranial pressure.
Less likely idiopathic intracranial hypertension (IIH aka psuedoteumor cerebri) given no signs of increased intracranial pressure though advised for prompt f/u with neurologist for re-evaluation which is appropriate given currently symptoms resolved making risks of further diagnostics (LP) outweighing low diagnostic utility and prompt outpatient diagnosis unlikely to cause morbidity.
COUNSELLING: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with proposed plan. All questions and concerns addressed and answered.
*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).