Case Study 2: Worst Headache of My Life

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 2: Tommy—Worst headache of my life

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A 22-year-old drummer is found unconscious by his girlfriend the morning after a performance and party. He tells her he woke up with a mild hangover and suddenly had a “horrible headache, and then I woke up with you here . . .” They write it off, but it happens again two weeks later. He also had a headache for about a day that resolved. He doesn’t have any other neuro symptoms or findings.

He had another sudden onset severe headache yesterday and came in this morning because it hasn’t completely gone away.

Question

  1. Electroencephalogram (EEG)
  2. Fundoscopic examination
  3. Lumbar puncture (LP)
  4. Magnetic resonance imaging (MRI)
  5. Non-contrast computed tomography of the head (Head CT)

The answer is:

  1. Fundoscopic examination.

  2. Non-contrast head CT.

  3. LP.

  4. MRI. (Some clinicians prefer doing a CT angiogram or MR angiography depending on availability.)

  5. EEG. (Not appropriate unless history suggests seizures, which are less commonly associated with history of sudden onset, “worst headache.”)

Sub-arachnoid hemorrhage

In a category called thunderclap headache SAH is 25%.

SAH 50% mortality + 25% morbidity.

Work-up if suspicious hx (esp if > 40; LOC; onset w/ exercise or + neck pain).

  • Hx and fundoscopic exam: Many have a “sentinal” leak.

  • Non-contrast head CT (95% sensitive @ 12h 50% @ 1wk).

  • LP: RBCs and increased protein; xanthochromia (after 4h) is almost 100% sensitive at 12h–7d.

  • MRI is needed if suspicion is high and neither CT nor LP are positive.

  • EEG is not part of this workup.

Urgent neurosurgical consult is required.

Secondary headache overview

A headache caused by an underlying condition, or worsening of underlying headache disorder through secondary means.

  • Mass effect (brain tumor, chronic subdural hematoma, infection, etc.)
  • Idiopathic Intracranial Hypertension (IIH) (previously Pseudotumor cerebri).
  • Trauma (including brain bleeds).
  • Vascular disease (bleeding, thrombosis, stroke).
  • Substance withdrawal (including medication overuse).
  • Trigeminal neuralgia.
  • Temporal arteritis.
  • Cervicogenic pain.

It is very important to identify potential red flag symptoms in secondary headaches; if concern for life-threatening condition, proceed with appropriate imaging. While non-contrast head CT is sensitive for bleeding and is often the first test in emergency settings, experts (“Choosing Wisely”) now recommend considering MRI as a first study in non-emergency settings or if significant pathology (“red flags”) is suspected, e.g. known cancer, vascular risks, etc.).

Address underlying condition; treat symptoms.

Medication overuse headache (MOH)

Secondary headache: Worsening of pre-existing primary headache disorder (usually migraine) through overuse of abortive and/or pain-relief medications.

Headache on 15 or more days of the month, due to regular overuse of headache medication(s) in a patient with a pre-existing headache.

  • New Daily Persistent Headache (NDPH).
  • Other secondary headache (esp. mass or increased ICP).
  • Management of withdrawal strategy and treatment of withdrawal headache using appropriate medication.
  • Prophylactic management of underlying headache disorder.

See this study looking at one-year outcomes from various treatment strategies. 

Image credits

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