Hot Seat #206: A Hazy Headache Hypothesis
Posted on: March 13, 2023, by : Walter Palmer
By Alicia Rolin, MD
HPI:
20YO female with no significant past medical history presenting with new daily headache x 1 month.
She has no history of headaches but reports new headaches since coming home from college for Winter break. She reports the pain is bitemporal and throbbing. She endorses occasional blurred vision, sensitivity to light, and nausea with her headaches. She feels more comfortable with her eyes closed and lying down. Each headache generally lasts 2-3 days and then resolves spontaneously. She has never tried an abortive medication (including ibuprofen). However, she has now had a persistent headache for the past 10 days.
She has remained afebrile. No infectious symptoms. ROS otherwise negative. No sick contacts. Fully immunized including meningitis. Takes OCPs. No other meds. Strong family history of migraines with aura.
Vital Signs:
T 37.4C
HR 96
RR 14
BP 130/83
SpO2 100% on RA
Wt: 102.7 kg
PE:
General: Alert obese female sitting up. Appears uncomfortable laying with eyes closed.
HEENT: Normocephalic, atraumatic. PERRL. Extraocular movements intact. Normal conjunctiva. +Photosensitivity.
CV: RRR. No murmurs, rubs, or gallops. Brisk capillary refill.
Resp: Comfortable work of breathing on room air. Lungs clear to auscultation bilaterally with no rhonchi, rales or wheezes. Good aeration. No dyspnea.
Abd: Soft, non-distended, nontender to palpation.
MSK: Moves all extremities. Normal muscle tone.
Neuro: Alert and appropriately oriented. CN intact. Normal strength and sensation. Normal reflexes. Normal gait.
Given the history, you order a migraine cocktail and get a CT head. CT head is notable for small but patent ventricles and mildly prominent optic nerve sheath complexes. “Increased intracranial pressure is not totally excluded.”
Because of the concern on the CT, you consult ophthalmology and neurology. Ophthalmology will examine the patient at bedside with a dilated eye exam. Neurology is recommending an LP. While you are discussing the CT results with ophthalmology and neurology, the patient finally receives her migraine cocktail. After the migraine cocktail, the patient feels back to baseline. She states this is the best she has felt in a month and family is asking to be discharged.
After a long discussion, the family agrees to the evaluation by ophthalmology but refuses the LP. Her dilated eye examination is completely normal. Ophthalmology has no concern for increased ICP. You discuss the results with Neurology who is still concerned for idiopathic intracranial hypertension and is still requesting the ED perform a lumbar puncture with opening pressure. She weighs > 100 kg. After a long discussion with the family, they reluctantly agree to stay for an LP.
It’s a real shame that we ED physicians need to consult Ophthalmology to perform a fundoscopic examination to r/o increased ICP. I think this is a core physical exam skill that we all should have!
Unrelatedly, did anyone ask the patient if she senses pulsatile tinnitus? Or if her headache worsens when she strains or bends forward and lowers her head down to her knees in a sitting position or if it worsens overnight or upon awakening in the morning? A 20 y.o. obese female on OCPs with a new persistent headache really needs to be ruled-out for pseudotumor cerebri/idiopathic intracranial hypertension (IIH). Failure to diagnose IIH is a potential lawsuit, given the concerns that it can permanently lead to visual field losses.
Does IIH improves or resolves with a migraine cocktail?
According to the study below, in a small sample of 68 patients with IIH, 45 (63.2%) also had migraine, although the reason behind the association is unclear. So perhaps this patient’s migraine headache was treated with the cocktail that she received!
Sina F, Razmeh S, Habibzadeh N, Zavari A, Nabovvati M. Migraine headache in patients with idiopathic intracranial hypertension. Neurol Int. 2017 Oct 2;9(3):7280. doi: 10.4081/or.2017.7280. PMID: 29071043; PMCID: PMC5641834.
I think that what amount of work-up is warranted depends on family comfort. I would, of course, prefer that we complete the workup in the ED while we have the patient present. However, if she feels better and the family wants to complete the work-up and management in the outpatient setting, that is completely reasonable. I definitely would not push them into performing an emergency LP (which might require sedation or even assistance by IR) if this could be safely arranged as an outpatient. This is definitely a case where I would use POCUS to determine the depth of the subarachnoid space; if it is deeper than 3.5in, then I would defer any attempts in the ED and arrange for the workup to be done with IR, and use family comfort to guide whether that happens urgently the next morning or during a planned visit.