Case: 45-year-old Woman with Headache

00:00 In this lecture we're going to talk about emergency causes of headache, and let's start with a case.

00:07 This is a 45-year-old African-American woman, and long-time smoker, who presents with sudden onset of severe headache and photophobia.

00:16 This is the "worst headache ever".

00:19 She presents to the emergency department where the headache is somewhat improved.

00:23 Vital signs are stable and she's afebrile.

00:26 On exam, the patient is drowsy and irritable with a non-focal neurologic exam but there is mild neck stiffness.

00:34 So, what do we see with this case? And what type of headache syndrome are we dealing with? Well, there's a bunch of buzzwords and key features that we should pick out of this presentation.

00:47 But first is, a lot of this sounds like a thunderclap headache.

00:50 This is rapid onset, severe headache, the worst headache of the patient's life, and those things should hone us in on evaluation of an emergent or thunderclap headache.

01:00 There's the presence of meningeal signs or meningeal irritation, that neck stiffness is important.

01:06 And we got to ask about it and look for it on the exam, stiffness and photophobia suggest meningeal irritation in the setting of a thunderclap headache for this patient.

01:16 And is it a primary or secondary headache syndrome? Well, this sounds like a secondary headache syndrome.

01:22 There's a cause to this.

01:24 We need to understand and figure out, diagnose, and maybe intervene on the cause of this thunderclap headache, this requires urgent management.

01:31 So what's the optimal management for this patient and headache? Immediate CT of the head without contrast, prescribe narcotics for symptom relief, perform lumbar puncture to evaluate for subarachnoid hemorrhage, or refer to ophthalmology to evaluate for papilledema and elevated intracranial pressure.

01:52 Well, we could think about performing a lumbar puncture, but that's not the best first step in managing this patient.

01:59 A CT of the head should be performed initially to evaluate for evidence of subarachnoid hemorrhage.

02:04 We're worried about subarachnoid hemorrhage, this sounds like a thunderclap headache, but the first step should be the CT of the head, and we may need to then pursue lumbar puncture depending on that result.

02:16 Prescribing narcotics may be performed for some patients but it's not the favor to board of treatment for this headache syndrome.

02:23 A narcotic may produce sedation which clouds our ability to follow the exam for this patient and our first step is really going to be evaluate the cause.

02:31 Referral to ophthalmology to evaluate for papilledema, we delay the diagnosis for this patient and it's not the appropriate initial step.

02:39 And so the right answer is immediate CT of the head without contrast to evaluate for subarachnoid hemorrhage.

02:46 And that's what was done in this case. And here is this patient's CT.

02:50 This is a non-contrast head CT and so what we're looking at around the outside you have the white hyperdense white findings of the bone.

03:00 Inside that is the gray brain and in the very middle of the brain we see white material and that's blood, it shouldn't be there on a non-contrast head CT, and that white filling the perimesencephalic cisterns and extending out along the MCA territory in the Sylvian fissure is blood and that's diagnostic of subarachnoid hemorrhage, the cause of this patient's thunderclap headache.