A 42-year-old woman comes to the office due to 6 months of worsening headaches. The patient has had occasional headaches in the past, but lately "they seem to be getting out of control" and are often throbbing. She also has constant, pressure-like headaches localized behind the forehead and eyes. The patient takes acetaminophen and ibuprofen and recently began taking them on a daily basis. The medications often make her nauseated, and she has had several episodes of vomiting. The patient also has blurry vision but no muscle weakness, syncope, or seizures. She experiences a considerable amount of stress at work and says that she "cannot afford to slow down." Medical history is significant for irritable bowel syndrome and chronic back pain. She smokes a pack of cigarettes daily. The patient's mother suffered from migraines and had surgery for a meningioma. Her father died of a drug overdose. Blood pressure is 155/98 mm Hg and pulse is 83/min. BMI is 27 kg/m². Chest examination is unremarkable. Abdominal examination shows mild periumbilical tenderness. There is no muscle weakness, and the deep tendon reflexes are symmetric. There is no hand tremor. Romberg test is negative. Funduscopic findings are shown in the image below. Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfeb_1e1b_8f63_ef8ca2fe9832_MD0005_00 Headache can be divided into primary (eg, migraine, tension) and secondary (eg, tumor, infection) causes. Patients without red flag features may be treated for primary causes, but those with such features (eg, fevers, papilledema) should be evaluated for secondary causes. This patient's worsening headaches, nausea, vomiting, blurry vision, and papilledema on funduscopy are all highly concerning for raised intracranial pressure (ICP). Her periumbilical tenderness could be from irritable bowel syndrome, nonsteroidal anti-inflammatory drug (eg, ibuprofen) use, or another intra-abdominal pathology (eg, primary mass lesion). Papilledema occurs when elevated ICP is transmitted to the optic nerve. Common causes include the following: Papilledema Mass lesions Increased cerebrospinal fluid production Decreased cerebrospinal fluid outflow (venous sinus thrombosis) Idiopathic intracranial hypertension (pseudotumor cerebri) Patients such as this one with a chronic daily headache and evidence of raised ICP should undergo neuroimaging, preferably an MRI with contrast. If there is a concern for acute subarachnoid hemorrhage (eg, acute onset, "worst headache of life"), noncontrast CT scan is preferred. (Choice A) Hypertensive emergencies may also present similarly, but the chronicity of this patient's presentation in the absence of significantly elevated blood pressure makes undiagnosed hypertension unlikely. (Choice C) A lumbar puncture to diagnose idiopathic intracranial hypertension may eventually be necessary. However, performing a lumbar puncture in the presence of raised ICP and a mass lesion places the patient at risk for brainstem herniation. Therefore, the first step in management is neuroimaging to exclude the presence of a mass lesion. (Choice D) Migraine or medication overuse headache can be severe and associated with nausea and vomiting, but papilledema is not seen with these diagnoses. (Choice E) Although cocaine intoxication may cause headache, the remainder of this patient's clinical features (eg, papilledema) are not explained by drug intoxication. Therefore, a urine toxicology screen would not be the best next step. Educational objective: Adults with headaches and red flag features should be evaluated for secondary causes. Headache and papilledema should prompt consideration of neuroimaging, preferably a brain MRI with contrast to evaluate for etiologies such as mass lesions and cerebral venous sinus thrombosis. References: Approach to acute headache in adults. (http://www.ncbi.nlm.nih.gov/pubmed/23939446) Primary brain tumors in adults. (http://www.ncbi.nlm.nih.gov/pubmed/18533376)

A 42-Year-Old Woman Comes to the Office Due to 6