A 56-year-old woman comes to the emergency department due to a severe headache that has not responded to over-the-counter analgesics. The generalized headache began 4 hours ago and rapidly worsened over several minutes. The patient has also experienced photophobia and an episode of vomiting and now reports vague discomfort in her neck and back. She has occasionally had headaches that were not as severe. She has a history of hypertension and takes lisinopril. The patient does not use tobacco, alcohol, or illicit drugs. She is an architect and reports high stress due to a large new project. Temperature is 37.3 C (99.1 F), blood pressure is 150/84 mm Hg, pulse is 94/min and regular, and respirations are 16/min. Pulse oximetry is 98% on room air. The pupils are equal and reactive. Extraocular movements and funduscopy are normal. There is mild neck stiffness, but muscle strength, deep tendon reflexes, and sensation are normal in the bilateral upper and lower extremities. Babinski sign is absent. The remainder of the examination shows no abnormalities. Noncontrast CT scan of the head is normal. Which of the following is the best next step in management of this patient?

Question

A 56-year-old woman comes to the emergency department due to a severe headache that has not responded to over-the-counter analgesics.  The generalized headache began 4 hours ago and rapidly worsened over several minutes.  The patient has also experienced photophobia and an episode of vomiting and now reports vague discomfort in her neck and back.  She has occasionally had headaches that were not as severe.  She has a history of hypertension and takes lisinopril.  The patient does not use tobacco, alcohol, or illicit drugs.  She is an architect and reports high stress due to a large new project.  Temperature is 37.3 C (99.1 F), blood pressure is 150/84 mm Hg, pulse is 94/min and regular, and respirations are 16/min.  Pulse oximetry is 98% on room air.  The pupils are equal and reactive.  Extraocular movements and funduscopy are normal.  There is mild neck stiffness, but muscle strength, deep tendon reflexes, and sensation are normal in the bilateral upper and lower extremities.  Babinski sign is absent.  The remainder of the examination shows no abnormalities.  Noncontrast CT scan of the head is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d541_5c23_bc81_73cccc1be4b0_MD0003_00 This patient has a sudden-onset, severe headache associated with photophobia, vomiting, and meningismus, suggesting subarachnoid hemorrhage (SAH). SAH most commonly occurs from rupture of arterial berry (saccular) aneurysms, resulting in sudden, severe pain (thunderclap headache), which many patients describe as "the worst headache of my life." Nausea and vomiting, brief loss of consciousness, and meningismus (eg, neck stiffness, often accompanied by back pain) are common, and many patients also describe a prodromal headache that may represent a sentinel bleed. Any patient with such a headache should undergo urgent noncontrast CT scan of the head, which may show blood in the basal cistern and cerebral sulci. The sensitivity for diagnosis using CT scan is very high, particularly within the first 6 hours after a bleed; however, minor bleeding, anemia, poor-quality images (eg, head movement), or increased duration since the event can markedly reduce the accuracy. Therefore, if CT scan results are negative, lumbar puncture (LP) should be performed in all patients with a high level of concern for SAH. Classic LP findings include elevated opening pressure, xanthochromia (yellow-pink discoloration due to hemoglobin breakdown), and a high red blood cell count that does not decline with serial collection tubes. (Choice B) Some studies indicate that MRI of the brain has similar sensitivity to that of CT, although data are limited. However, MRI takes significantly longer than LP, which can delay treatment and lead to significant morbidity and mortality. (Choice C) Inhaled oxygen is indicated for the treatment of cluster headache, which presents as unilateral, stabbing periorbital pain associated with ptosis, lacrimation, or rhinorrhea. Cluster headache typically occurs in young men. Meningismus is unexpected. (Choice D) Nonsteroidal anti-inflammatory drugs are used for tension headaches (bilateral, bandlike pain). Although this type of headache is often associated with stress, it usually has a gradual onset and is only moderately painful. This patient requires LP to rule out SAH; reassurance would increase morbidity and mortality. (Choice E) A triptan (eg, sumatriptan) is an abortive therapy for migraine. Although photophobia and nausea are common with migraine, the headache is typically throbbing and unilateral, and meningismus would not occur. Educational objective: Subarachnoid hemorrhage (SAH) results in sudden-onset, severe headache; nausea/vomiting, brief loss of consciousness, and meningismus are common. Patients should undergo an urgent noncontrast CT scan of the head; if results are negative and a high suspicion for SAH still exists, lumbar puncture should be performed.

A 56-Year-Old Woman Comes to the Emergency Department Due to a Severe