with Moh Saidinejad, Children's National, on the Hot Seat
The Case
Mother states patient infrequently wakes up with a headache. No fevers, neck pain , runny nose, nasal congestion. She has been keeping a headache diary but not food/fluid intake intake diary in conjunction. Patient does not drink any caffeine and takes approximately 64 ounces of water per day. Mother and patient have been actively working on healthier diet and lifestyle. Patient has an upcoming appointment with a neurologist but has worsening headache.
PMH: Not significant
PSH: Adenoidectomy
FH: Maternal side- history of various CA, but no brain tumors
SH: Lives at home with mom.
Vital Signs T: 36.6 HR 73 RR 20 BP 104/67 O2 Saturation 100% RA Wt. 88kg
Gen: Well appearing, well nourished, no acute distress, does not appear uncomfortable
HENMT: NC/AT, normal Tms bilaterally, normal nasal exam no evidence of swollen turbinates or rhinorrhea, MMM, oropharynx clear
Eyes: PERRL, Optic disc margins sharp
CV: WNL
RESP: CTAB, normal WOB
GI: soft, non-tender, non-distended, no hepatosplenomegaly
Neuro: No focal neurological deficits, sensation intact, normal gait
Questions for you (answer according to your PEM experience)
Case continues: She receives an IV “migraine cocktail” with improved symptoms, and is sent home with instructions for NSAID restriction and with Benadryl and Compazine q 12 hours prn headache. She returns one week later with worsening generalized headache, eye pain (left greater than right), and neck pain for the past few days. She has tried acetaminophen, ibuprofen, and Excedrin with no relief. + occasional nausea, no emesis. Headache is worse when patient bends over.
T: 36.3 HR 77 RR 18 BP 116/67 O2 saturation 100%
Exam is unchanged.
One more question for you
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Come back later for the denouement of this case
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
No comments? i guess everyone is at PAS !
ReplyDeleteMy approach is to:
1) evaluate for signs consistent with migraine-type headache
2) evaluate for risk factors associated with idiopathic intracranial hypertension (obesity, GH, doxy, other meds)
3) evaluate for signs of viral or aspetic meningitis (exposures, neck flexion pain)
4) evaluate for signs of sinusitis (chronic cough, facial tenderness, rhinorrhea)
5) look for physical exam signs of something intracranial
But when difficult to localize to anything other than "headache" and if symptoms not classically migranous, this often means........use IV meds but if not improved, CT and LP.
One of the great questions in an 11yo is how practically to do an LP. Ketamine increases intracranial pressure so not a great option if you want to measure OP. I've had some recent success with a single IV benzo and J-tip prior to lidocaine SQ. I don't think typical sedatives (pentobarb, benzos) in isolation work that great because the kids always flinch with the lidocaine. So either a J-tip, EMLA, or addition of an IV pain med are usually necessary in this age group. When evaluating for meningitis and not intracranial hypertension (fever, summertime, Lyme, etc)....i do use ketamine and there is plenty of evidence that there is not a significant increase in intracranial pressure. But if doing the LP for the number (OP) i don't think it's worth the risk.
oh, and 64 oz of water a day is a lot so good to make sure the kid doesn't have DI or something weird that could be associated with an intracranial something like a craniopharyngioma. But i assume this kid got labs when she got an IV the first time around. I personally don't give IVF routinely without having a BMP....every once and a while a kid will have a creatinine of 2 or a sodium of 160.
DeleteHOT Seat Response:
ReplyDeleteLooking at the facts in the case:
1) Obese 11 year-old female with headaches
2) Headaches are intermittent and have been going on for a couple months
3) Looks like no associated symptoms (photophobia, neck stiffness, etc...)
4) Taking NSAIDs around the clock - probably too much
5) Nothing exciting on the family history or physical exam - assuming the funduscopic exam with sharp disk margins are complete and reliable
I agree with a lot of what Dave said.
DDX:
A) Idiopathic Intracranial hypertension (obesity, possible Polycystic ovaries, maybe retinoids for acne? We don't have a medication history though, or acne hx.
B) Sinusitis and sinus headaches - one nugget of information I learned long time ago is that sinus headache definitely gets worse with bending forward as in this case.
C) Other headache types (migraines, stress headaches, cluster or tension headaches).
D) Infectious - Encephalitis, meningitis (viral first, then other causes). If it were bacterial, it probably would not have dragged on two months without serious problems. Included in there is brain abscess
E) Mass- either benign (e.g. meningioma) or malignant - includes posterior fossa tumors,) Other masses such as pituitary adenomas, CA, etc..
F) Intracranial anatomical issues (large CSF obstructing cysts, AVM, sinus thrombosis).
G) Post concussive (very prolonged) headache – not likely here.
H) Everyone's favorite: Psych stuff: somatization, conversion, malingering (drug seeking - less likely in an 11 year old), psychological stress from bullying, etc...
I) Medication induced headache from too much NSAIDs
At this stage, I would first make sure that I get a great exam myself, including the fundoscopic exam, motor, sensory, and gait.
* I would do a CBC with differentials, a BMP (pituitary, craniopharyngiomas as Dave mentioned) checking Na. K, Cr and a UA (fishing for DI)
IF LABS ARE OKAY TO ALLOW IVF
* Then, I would try migraine headache protocol (IVF, ketrorolac, metoclopropamide or even ondansetron which is supposed to have headache as side effect, but works with migraines). I know I said that too much NSAID headache is on my differentials, but I really want to see what the response to migraine protocol is.
IF NO RESOLUTION OF PROBLEM,
*I would do a head CT (first a non-contrast plain CT to evaluate for mass, bleeding, ventricular size, and status of the sinuses)
IF NO ANSWER FROM THE CT
* Then I would do an LP. I honestly don't think the latest literature supports the caution about ketamine and increased ICP. I would actually like ketamine as single agent for its amnestic, analgesic, and sedative properties, if it looks like local lidocaine and j-tip is not sufficient.
IF NOTHING EXCITING ON THE LP
ASSUMING NO MASSES, NO CSF PLEOCYTOSIS, PROTEIN ELEVATION, AND NOTHING TO SUGGEST SINUS DISEASE
* I will be back to one of the other types of headaches mentioned.
What am I missing? I assume this kid is not immune compromized, and has no foreign travel to prompt exotic etiologies. At this point, I have reached the end of my 2-3 hours of ED evaluation and the patient either needs to be discharged with outpatient follow up or be admitted. I vote for neurology, but if gen med takes them, great.
If discharge:
* I would try to get the neurology appointment expedited
* Also refer them back to PCP to consider outpatient psych evaluation if all medical issues come up empty.
Would I try to get an MRI/MRA during the ED visit to get a better look at posterior fossa and other structural details, and the cerebral vasculature and look for microaneurysms? Maybe, if I can get one done very quickly, but this should be able to be done as outpatient, especially if we have the negative CT in the bag.
What do I think are the top 4 on my list?
1) Sinus headache
2) Ideopathic Intracranial hypertension
3) Migraine headcahe
4) A mass
Since this is hot seat and the case is probably more on the extreme side, I would go with brain mass.