with Moh Saidinejad, Children's National, on the Hot Seat
The Case
This is a case of an 11 y/o obese female presenting with intermittent, increasingly severe headaches x 2 months. Her initial exam showed no focal neurological deficits, intact sensation, normal gait and sharp optic disc margins. The case focuses on treatment and diagnostic dilemmas. Mohsen, our Hot Seat attending for this case, uses the case as a reminder of the broad differential diagnosis for headaches and also gives great rationales for clinical decision making. For the full case presentation, click here. What medication strategy would you order initially to treat her headache?
LESS than 3 yrs PEM experience (n=16)
MORE than 3 yrs PEM experience (n=6)
With regards to medication strategy, it is interesting to note the varying preferences among experience of providers. 56.3% of providers with less than 3 years experience would start with a bolus/ketorolac/metoclopramide PLUS diphenhydramine. This is compared to the 16.7% of providers with more than years experience. On the other hand, 50% of PEM providers with more than 3 years experience preferred bolus/ketorolac PLUS metaclopramide or similar. This indicates that many of our more experience providers are opting to eliminate diphenhydramine from their migraine cocktails. In the less than 3 years experience group, equally split (12.5%, n=2 each) were IV fluid bolus with ketorolac, bolus/ketorolac PLUS metaclopramide or similar, or a different medication plan. Only one person (in the less than 3 years experience group) chose a trial of triptan only. In both groups no one would start with a PO analgesic (ibuprofen, acetaminophen).
If your patient does NOT respond to your medication plan, rate your likelihood of obtaining a CT this visit:
LESS than 3 yrs PEM experience (n=13)
MORE than 3 yrs PEM experience (n=7)
In terms of the utility of head CT, the responses were split in both groups. The majority of providers with less than 3 years experience were split between likely and somewhat likely getting a head CT (38.5%, n=5 each). Providers with more than 3 years experience were split between not likely, somewhat likely and very likely getting a head CT (28.6%, n=2 each). None of the providers with less than 3 years experience were very likely to get a head CT.
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.
Do you think this patient must have an LP prior to leaving the ED?
LESS than 3 yrs PEM experience (n=13)
MORE than 3 yrs PEM experience (n=7)
The majority of both groups (76.9% and 71.4%) would do an LP prior to the patient leaving the ED, but would perform a CT first. Of the providers with less than 3 years experience, 7.7% (n=1) would get an LP but believed a CT was not necessary beforehand. None of the providers with greater than 3 years experience shared this opinion. One provider in the greater than 3 years experience group would wait for MRI and then LP.
Clinical Reasoning
A great thank you to Dave and Jim for your comments. Below is an excerpt of a few clinical reasoning pearls but reading their comments in full is recommended.
“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.” – Dave Mathison, Children’s National
“The standard of care would require and examination of the optic disks.” – Jim Chamberlain, Children's National
“Either a J-tip, EMLA, or addition of an IV pain med are usually necessary [for LP] in this age group. …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.” – Dave Mathison, Children’s National
From the Hot Seat
by Moh Saidinejad, Children's NationalLooking 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 fundoscopic 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, ketorolac, metoclopramide 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 compromised, 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) Idiopathic Intracranial hypertension
3) Migraine headache
4) A mass
Since this is hot seat and the case is probably more on the extreme side, I would go with brain mass.
The Denouement
by Sylvia Ansah, Johns Hopkins
The patient presented to the emergency room twice secondary to a history of headaches and nausea over one month, with the headaches becoming more severe and constant. She went to the ED for her second time with worsening headaches and blurred vision, and vital signs were relatively stable. She appeared in no acute distress initially, but had worsening headaches upon lying down and complained of 10/10 pain. There was questionable papilledema by the ED attending and confirmed papilledema by ophthalmology. She underwent a MRI on the second visit to the ED, which demonstrated obstructive hydrocephalus and Chiari I malformation. She had no previous history. She was admitted by neurosurgery and she had placement of a VP shunt with a strata programmable valve set at 2.0. She tolerated procedure well, and was in stable condition on intravenous antibiotics. During her postoperative course, her vital signs remained normal. There was no bradycardia and she remained afebrile throughout her postoperative course. Her blurry vision and headaches resolved status post VP shunt placement. She was discharged home on the first postoperative day, tolerating her diet without difficulty.
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