What Would You Do?: Headache

A 23 y female presents to your Emergency Department at 4:30 in the morning. She is complaining of having a headache that started at 3:00AM. She had taken some Motrin for the pain. At 3:15AM, she received a phone call and noticed that when she was talking on the phone she was stuttering. She became scared and soon noticed that she had upper lip numbness as well as R hand numbness. She attempted to read something and found that she had difficulty understanding what she was reading. Her headache wasn’t the worst that she has ever had and came on gradually. She denies fever, chills, nausea or vomiting.

What course of action would you take with this patient? Would you perform an LP? Would you perform a CT scan? Would you first treat and see how she does? Please offer your suggestions regarding management and any supporting articles and reasoning that might help guide a young doc working alone in the middle of the night.

8 Comments on "What Would You Do?: Headache"

  • This patient has clearly earned more than just the benadryl/reglan cocktail. While they may just be having an atypical migraine without any known h/o such it shoulder be treated much more seriously especially given her history. First the pt should receive a neuro exam to try to narrow down the differentialls. However even with a normal neuro exam this pt should be sent for a noncon head CT. If this was negative I’d consider CT angio or MRI if possible emergently. Depending on the results of these studies the pt should also receive an LP (possibly not emergently but at some point) looking for cell counts, monoclonal proteins, bleeding etc. Differentials for this patients include atypical migraine, CVA, aneursym, mass, bleed, meningitis, MS/MM or other chronic neuro d/o. Utox and ETOH levels are also warranted for this pt as well as labs including CK/electrolytes and EKG.

  • So there’s this pt. with a headache. It was neither sudden nor severe, and it came on gradually. She had neurological complaints including speech and sensory, as well as a diff. with comprehension of reading. Medicalese would be dysarthria, numbness/paresthesia, and either a weird conduction aphasia (as these types of complaints typically involve spoken language) or a visual disturbance.

    We are not told whether they persisted or what her neuro exam currently is. For the sake of clarity, I will assume that all sx resolved and her exam is normal. Now what?

    SAH? She is a low risk pt. by virtue of her age, and lack of HTN, neck pain or vomiting. Further, her sx are more typical of focal neuro perhaps TIA type c/o. Having described focal deficits, will we likely do a CT? Yes. When it is done we will have a neg. non-contrast CT done w/in 6 hrs, and both the camps for and against SAH in this case will be satisfied. Low risk + early 16+ slice scanner = done. See Perry’s 2008 and 2010 articles in BMJ in an easy google search or simply go to EMRAP to get the overview and dissenting opinion.

    Stroke/TIA? Sx resolved, super young, well-appearing, so… who cares? CT neg and output. Neuro F/U with perhaps oral ASA to make us feel like we’re doing something. (The discussion of ABCD2 utility is beyond my patience but let’s just say that she gets a point for speech and perhaps one for duration.)

    But HA is her cc. HA and stroke don’t go together. Unless there’s a mass or a bleed (neither of which we’re about to miss on non-con CT) this is not a stroke. What could it be? The list populated above is fine but I’d remove meningitis given the limited info we have. MS a good ddx but if sx resolved the eventual ex may take a while. Sx separated in time and space need, you know, time. So let’s leave the LP and MRI for the Neurons.

    For pain + focal neuro c/o I’m thinking carotid dissection. So yes, I’m still getting that imaging study even for those who would’ve scoffed at the poss. of SAH, but I’m following the non-con with immediate CT Angio. But not to r/o SAH, to rule in carotid dissection. So you have to start at the neck and tell your radiologists. And while my brain is in this ballpark, she absolutely needs a pregnancy test.

  • Atypical migraine is definitely at the top of my differential followed by some sort of vascular event. Head CT is a definite. Carotid dissection seems like a possibility although incredibly rare (1.72 per 100,000 according to Uptodate). Arguing for the dissection is the involvement of the speech center which is located in most people on the left side of the brain as well as the R hand numbness. Neuro consult should be involved in this case.

  • Pik this was an awesome presentation and differential diagnosis of a very often taken for granted mundane presentation

    summation

    pt pted with what sounds like transient partial (not complex partial which would include a loss of awareness) seizure vs hemiplegia (jacksonian) vs a lesion occupying real estate that would take out the face ( didn’t hear what side of the lip was involved ) rt arm and speech issues (manifested by an inability to understand written language). The last item is less likely because of transience of its duration and hemiplegic migraine is at least in the top two of final diagnosis. dispo workup depends on availability of consultants/services

    but

    ct head neg excellent to r/o blood based on the duration of symptoms (checked with my encyclopedia Cubero to confirm this) resolution of symptoms with headache goes well with seizure or migraine. in so well looking a patient with transient symptoms MS is much less likely and so is (sorry to shoot down so sexy a diagnosis) is carotid dissection.

    reglan benadryl
    continue nsaids
    ed versus semi urgent neuro referral to arrange mri’s and eeg
    no TRYPTANS (contraindicated in hemiplegic migraine-at least for now see http://www.ncbi.nlm.nih.gov/pubmed/17718700 )
    rtedprn
    at monte she has a 50:50 chance of admission

    poopooh to lp

    Tonynap:-)

  • interesting case. let me make it a bit more controversial. say the symptoms still persisted at the time of presentation in the ED?

    would you activate the stroke team?
    would you tpa her when the CT head is negative?
    arguably, this is not the worse headache of her life. would you LP her?

    i’m not sure how utox/etoh will help me with this case.

    LA

    ps. the case variation i presented above is a true case i saw at monte =)

  • Tony-

    That sounds like an appropriate tx for hemiplegic migraine. So you’re going to make that dx on a 23 yo with no hx of headache or migraine?

    You’d better give me a unilateral, throbbing, pounding H/A of gradual onset, with a pt. who may not have a hx of similar H/A but definitely gets chronic H/A’s not like this, and perhaps a family hx of migraine. And even then they are likely getting the CT w/in 6hrs for “new/changed.”

    But if that’s not the hx, this chick is getting some IV dye. (btw, had a pt. with waxing/waning sx who got admitted before making this dx- sx cleared entirely btw episodes, neuro said it was psychiatric. Not sure I buy the: “sx too short or resolved = not dissection”.)

    -pik

  • my case presented at monte with severe (though not the worst) headache, L arm weakness <1.5 hours duration. stroke team activated.
    ct head negative.
    monte icu attending came down to LP the patient.
    i reminded her that if she LP's the patient and it's negative, we won't be able to give tpa.
    Neurology agrees, and we decided to do CTA, then called the neurorad at 11pm, and asked if there is anything remotely resembling an aneurysm.

    had a long discussion with the patient.
    he wanted tpa.
    his argument was that it took 12+ years of training to do his job, and now he won't be able to work without the use of his arm. He clearly understood the risk vs. benefit for iv tpa.

    cta negative for aneurysm per neurorads.
    tpa started (this all happened within at most 1 hour, go monte!) while pt was being wheeled to MRI….

    MRI was clean. pt had new onset hemiplegic (complex) migraine..

    if he had nonaneurysmal bleed, he would have been dead. our argument for giving the tpa was that if he truly has a subarachnoid bleed that would cause his L arm to be weak, we should see something. an argument was raised that what if the L arm weakness was 2/2 cerebral artery vasospasm from a tiny bleed? patient was made aware of this, and the neuro team/neurosurgery team agreed that this would be very very rare and very unlikely.

    still. tough case.

    here's another one. you have a 60m s/p head trauma from MVC patient, significant damage to car, otherwise healthy, now unable to move L side of body.
    CT head negative. CT c-t-l spine negative.
    CTA neck + for carotid dissection. would you heparinize the patient?

  • It’s a decent argument, but far from foolproof. It’s like if you have a guy who clutches his head and falls over unconscious. His head CT is negative, but have you ruled out SAH? After all, we like CT, then LP if negative. I would argue that a pt. in a coma is NOT the sentinel bleed that we are afraid of missing, and that like your pt. with the arm symptom, I would expect to see a shit-ton of blood.

    BUT, as in my first post, H/A with a stroke is NOT common. So if the CT is negative for bleed and shift and you have a neuro complaint, stroke actually moves down the ddx to a lower likelihood. Migraine and carotid dissection would move up. Of those two, I basically don’t care about migraine since Reglan will cure it and make the neuro complaint resolve.

    SO to answer the last bit of your past Al, YES, if you have a dissection, heparin or even t-PA can be an option- and that is a bit ballsy in a guy having a stroke, but totally medically reasonable. Discuss with your consultants.

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