A 44-year-old woman comes to the emergency department complaining of several hours of severe occipital headache. The headache is described as intense and began suddenly when she was climbing up the stairs at the local subway station. She rested at home for 6-7 hours after the onset of symptoms, but the headache remains persistent and unbearable. The patient has mild nausea but no vomiting, blurry vision, muscle weakness, or syncope. She has a history of moderate-intensity tension headaches that concentrate around the temple. The patient has been taking over-the-counter pain killers for these headaches recently but states that this current headache is worse and differs from her usual pattern. She also has a history of mild intermittent asthma and dysmenorrhea. She has a 15-pack-year smoking history. Her temperature is 98 F (36.7 C), blood pressure is 142/90 mm Hg, and pulse is 95/min. She is in significant distress due to pain but is cooperative. There are no focal neurologic deficits. Non-contrast CT scan of the head shows no intracranial abnormality. Which of the following is the best next step in managing this patient?

Question

A 44-year-old woman comes to the emergency department complaining of several hours of severe occipital headache.  The headache is described as intense and began suddenly when she was climbing up the stairs at the local subway station.  She rested at home for 6-7 hours after the onset of symptoms, but the headache remains persistent and unbearable.  The patient has mild nausea but no vomiting, blurry vision, muscle weakness, or syncope.  She has a history of moderate-intensity tension headaches that concentrate around the temple.  The patient has been taking over-the-counter pain killers for these headaches recently but states that this current headache is worse and differs from her usual pattern.  She also has a history of mild intermittent asthma and dysmenorrhea.  She has a 15-pack-year smoking history.  Her temperature is 98 F (36.7 C), blood pressure is 142/90 mm Hg, and pulse is 95/min.  She is in significant distress due to pain but is cooperative.  There are no focal neurologic deficits.  Non-contrast CT scan of the head shows no intracranial abnormality.  Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c006_bc88_8f63_0b86ced6d173_MD0005_00 This patient's presentation is concerning for subarachnoid hemorrhage (SAH), which is most often due to a ruptured saccular aneurysm. SAH typically presents with sudden onset of a severe headache and possible nausea, vomiting, brief loss of consciousness, focal neurologic deficits, or meningismus. Patients usually develop a suddenly worsening headache different from their typical headache pattern, or experience an intense new headache described as "the worst headache of my life." The headache is typically lateralized to the side of the aneurysm and can correlate to rapid spread of bleeding. Even though this patient has a history of chronic tension headaches, her current headache is more intense and differs in character and location (occipital area) from her usual headaches. Noncontrast head CT is the preferred initial test to establish the diagnosis of SAH. Head CT performed within 6-12 hours of SAH onset is nearly 100% sensitive for diagnosing SAH, but this rapidly decreases with increased time from SAH onset and smaller hemorrhages. As a result, lumbar puncture (LP) is required to completely exclude suspected SAH in patients with a negative noncontrast head CT. The typical cerebrospinal fluid (CSF) findings in SAH include an elevated opening pressure, xanthochromia (pink/yellow tint due to hemoglobin degradation products), or consistently elevated red blood cell (RBCs) count in the 4 CSF tubes. An elevated RBC count in the first tube, followed by declining numbers of RBCs with each successive tube suggests a traumatic tap. Retained CSF blood can take up to 6 hours to degrade and cause xanthochromia; for this reason, LP is most sensitive >6 hours from SAH onset. (Choice A) Acetaminophen combined with aspirin and caffeine can effectively treat tension headaches refractory to initial nonsteroidal anti-inflammatory drugs. However, this patient first needs LP to exclude SAH before being treated for tension headaches. (Choice B) This patient's headache could be due to recent use of over-the-counter pain killers causing rebound headache. However, this is a diagnosis of exclusion, and LP should be performed first to rule out SAH. (Choice D) An MRI of the head has similar sensitivity to a head CT for diagnosing SAH. This patient's head CT is negative; as a result, she requires LP to definitively exclude SAH. (Choice E) Triptan medications are generally more effective for migraines than for tension headaches. Educational objective: Subarachnoid hemorrhage typically presents with sudden onset of severe headache and possible nausea, vomiting, brief loss of consciousness, focal neurologic deficits, or meningismus. Patients usually develop a suddenly worsening headache different from their typical headache pattern, or an intense new headache described as "the worst headache of my life." Noncontrast head CT is the initial preferred test for diagnosis, followed by lumbar puncture to document xanthochromia if the head CT is negative. References: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/22556195) National guidelines for analysis of cerebrospinal fluid for bilirubin in suspected subarachnoid hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/14503985)

A 44-Year-Old Woman Comes to the Emergency Department Complaining of Several