Hot Seat Case # 108 Denouement: 17 year old male with an intractable headache

Posted on: March 8, 2018, by :

Daniella Santiago-Haddock, MD Inova Children’s Hospital

Case: 17 yo male with a history of migraine headaches and negative brain imaging one month prior to presentation with persistent headache. He presented with worsening headache despite home NSAID’s and Sumitriptan despite a history of non compliance to both pharmacologic and non-pharmacologic therapies. His mental status exam changed acutely during his evaluation in the emergency department, after some therapies had begun.

Here’s How You Answered Our Questions:

The “other” answer for poll question one was a fundoscopic exam to look for papilledema.

Discussion:

This was a case that took an interesting turn while the patient was evaluated and awaiting admission in the emergency department. The group agreed that based upon the initial history and presentation as well as examination findings, highest on our differential remained migraine exacerbation, but a very detailed neurological examination is key in these patients. Occasionally subtle cerebellar or gait abnormalities are found but not always tested in the emergency department.

The turn in management and workup came when the patient became altered and as Dr. Zhao mentioned, not showing evidence of extrapyramidal symptoms that we would anticipate from Compazine. Everyone was in agreement that head imaging would be important and necessary with very few opting for the lumbar puncture without prior imaging. An interesting prospective study (link below) looking at adults with suspected meningitis found some clinical features that were associated with an abnormal Head CT.

History:

  1. An age of at least 60 years
  2. immunocompromised
  3. A history of central nervous system disease
  4. A history of seizure within one week before presentation

Physical Exam:

  1. An abnormal level of consciousness
  2. An inability to answer two consecutive questions correctly or to follow two consecutive commands
  3. Gaze palsy
  4. Abnormal visual fields
  5. Facial palsy
  6. Arm drift or leg drift
  7. Abnormal language (e.g., aphasia).

The patient had none of the historical findings but did have physical exam findings 1, 2, and 7 without clear mention of 3, 4, or 6.

The final point brought up both in discussion as well as the message board was choice for sedation if needed for the Head CT. Most of the group preferred something short acting, realizing that choice of agent may be institution specific. Propofol, precedex, or pentobarbitol were preferred agents, however, if none of these are available midazolam would be the next best option. We would all stray away from lorazepam as it is too long acting for our needs.

Denouement:

The decision was made to hold off on the admission, and order labs and head CT. Parents were also consented for the lumbar puncture to be completed after the head CT results. The imaging revealed bilateral subdural hemorrhages that appeared to be acute on chronic, with associated edema and shift. He received a dose of Mannitol in the ED after evaluation by Neurosurgery, and was admitted to the PICU. He was taken to the OR urgently for evacuation, but, unfortunately the source of the bleeding was never determined after more in-depth imaging and a bleeding disorder workup per Hematologies recommendations.

https://www.ncbi.nlm.nih.gov/pubmed/11742046

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

3 thoughts on “Hot Seat Case # 108 Denouement: 17 year old male with an intractable headache


  1. Interesting that his initial Head CT was normal just a week earlier. Did anyone ever document that fundoscopic exam I suggested was necessary? If he had bilateral bleeds as the source of his headache (with associated edema and shift), I suspect it would have shown papilledema and an urgent head CT would have been obtained before his deterioration. Just saying 🙂


    1. The most effective agent for hypeosmolar therapy has been long debated without clear evidence to change many peoples practice as of yet. I think the choice may be institutional specific, but, I would have used HTS in these instances. The most recent lit review from 2015 concluded that there was no clear superiority between agents. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4665128/

      Hopefully once some prospective RCT’s come out in the near future it will all give us a clear answer to transition our practice from Mannitol to HTS.

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