Hot Seat #155: An Adolescent Headache
Posted on: August 24, 2020, by : Marci Fornari
HPI: An otherwise healthy 17-year-old female presents with a persistent headache for three days. The pain initially started on the left side of her head, but is now worse in the frontal area and radiates to the temporal region. Currently says her pain is 2/10, but it was 6/10 at time of onset. She recalls having multiple episodes of NBNB emesis on day one of headache due to pain, but none since then. Denies photophobia, phonophobia, visual floaters, double vision, or dizziness. She denies this being the “worst headache of his life”. The headache has not woken her from sleep and is not positional. Denies neck pain or fever. She is tolerating PO. Tylenol provides mild relief. No history of trauma. No recent stressors. LMP 2 weeks ago.
PMHx: no history of headaches/migraines. She does not wear glasses.
Immunizations: Up to Date
Family History: no family history of migraines
Social History: Lives at home with mom and dad
Review of Systems:
Constitutional symptoms: tired, but no fever, normal PO intake
Eye symptoms: no pain, no blurry vision, no double vision
ENMT symptoms: no ringing in ears, no congestion
Gastrointestinal symptoms: NBNB emesis, no abdominal pain, no nausea, no diarrhea
Musculoskeletal symptoms: no neck pain, no back pain
Neurologic symptoms: Headache, no dizziness, no seizure, no altered level of consciousness, no numbness, no tingling, no weakness
Physical Exam:
T 36.7 C, HR 67, RR 18, BP 130/90, SpO2 100% on RA
General: alert, appropriate for age, no acute distress
Skin: warm, dry, no rashes
Eye: PERRL, EOMI, normal conjunctiva
ENT: normal TMs, moist oropharynx
Neck: Supple, no tenderness, no lymphadenopathy, full ROM without pain
CV: regular rate and rhythm
Respiratory: CTAB
MSK: normal ROM. Normal strength in upper and lower extremities
Neuro: Alert, CN II-XII intact, normal sensation, normal motor, normal speech, normal coordination, negative Romberg, normal gait
The patient was discharged home with Motrin/Tylenol PRN for pain and instructions to follow-up with her PCP.
She returns to the ED two days later due to persistent headache. She reports that headache varies in intensity from 2/10 to 6/10, and radiates to her eyes. She endorses nausea and photophobia, but no vomiting, no blurry vision, no double vision, and no fevers. Overall, she reports that she feels mildly improved from her previous ED visit, but is worried because the headache has not gone away. Her repeat vital signs and physical exam, including a detailed neurologic exam, are all normal.
The patient was again discharged home with Motrin/Tylenol PRN and instructions to follow-up with her PCP.
She returns to the ED five days later due to persistent headache. She reports that the pain continues to vary in severity from 2/10 to 6/10, and it is worse on the left side. She has now developed blurry vision and double vision. Reports minimal improvement in pain with Tylenol and Motrin. Denies fevers and she is tolerating PO. There is no family history of brain aneurysm, migraines, or ocular disease.
Physical Exam
T 37 C, HR 58, RR 18, BP 128/80, SpO2 100% on RA
Neuro: left upper eye lid droop. left pupil is 6mm and sluggishly reactive to light, right pupil is 4mm and briskly reactive to light. EOMI. CN III palsy, CN II, IV-XII intact. 5/5 strength. normal sensation. normal coordination. normal gait.
Physical exam is otherwise normal.
STAT CT Head was obtained and read as normal. Ophthalmology performed a fundoscopic exam and saw no papilledema. Neurology recommended a MRI Brain, but one was unable to be obtained at this time in the ED. Patient’s headache continued to be mild, vital signs were stable and physical exam remained unchanged.
With a normal head CT, I would perform an LP with opening pressure. If OP high, may be vision-saving procedure if this is pseudotumor.
I would assume that if idiopathic intracranial hypertension is severe enough to cause vision changes, should be bilateral, and also have evidence of papilledema. Bedside US will help assess optic nerve sheath diameter and estimate increase (ICP) if > 5-6mm. With a normal CT and pending the MRI, I would explore other causes of ipsilateral nerve palsy such as Parinaud’s Syndrome (however normal TM), bartonella exposure, tuberculosis, or Lyme disease. Other headache differential would include hemiplegic migraine. Finally other etiologies to consider include RCVS (although presents more classically with persistent thunder-clap headaches) or PRESS (which usually involved occipital area more than frontal and is associated to seizures and altered mentation) and could be confirmed with MRI / MRA or CTA.
The data for ONSD is a little unclear and the technique of obtaining a measurement needs to be very precise. If you can’t start with a good ophthalmologic exam (because who can see the optic disc with our crummy ophthalmoscopes in a well lit ED with non dilated pupils??) to check for papilledema, POCUS can easily reveal a raised optic disc which (with a negative CT) can prompt a diagnostic and therapeutic LP for idiopathic intracranial hypertension as Jim recommends.
That took a difficult turn.
The first half of the presentation, I was thinking about prolonged headache in an adolescent with a normal neuro exam and reassuring VS (initial BP was a bit high but likely not sufficient to cause HA). Ddx included tension headache, migraines, rebound HA from continued NSAIDs/acetaminophen. Less likely but still on the ddx might be meningitis (viral, Lyme), space-occupying lesion, SAH, CVST.
Then she returns with a CN III deficit. This would seem to narrow the differential with some of the same diagnoses as above- space-occupying lesion, CVST, CVA. Need to add in auto-immune conditions such as MS. Not sure if a migraine can cause such a specific exam finding.
Next steps: imaging with contrast; likely thrombosis workup; Neuro consult.