Case 33: Headache

Opening scenario

Carol Meyers, a 55-year-old female, comes to the emergency department because of a headache.

Vital signs

• Temperature: 101.7°F (38.7°C)
• Blood pressure: 145/95 mm Hg
• Heart rate: 100/min
• Respirations: 19/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act as if you have the worst headache of your life. It gets even worse when you are exposed to bright lights and loud noises.
• Pretend you are disoriented when it comes to the current time and date. Give the examinee an incorrect answer if asked for the current date. You are unable to recall the name of the current president of the United States.
• You have a very stiff neck. When the examinee tries to flex it while you are in a standing or sitting position, say that it hurts and resist flexion, only allowing your head to be tilted forwarded slightly and not letting your chin touch your chest.
  • When you are lying down and the examinee tries to lift your head so your chin moves toward your chest, pretend to be in pain and bend your legs at the hip.
  • When you are lying down and the examinee lifts your leg and tries to straighten it, pretend to be in pain and bend it at the hips.
• You are not aware of the meanings of medical terms (e.g., CT, lumbar puncture) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Interrupt the examinee while he/she is taking your history and say “I need to call my husband and tell him where I am! He went to the cafeteria just before I was called in here, and I am sure he is worried sick right now!” If the examinee lets you call him, pretend not to reach him. If the examinee does not let you contact your husband, start arguing with her/him.

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I have a horrible headache.
• Location
• My entire head hurts.
• Intensity (on a scale from 0–10)
• A 10.
• Quality
• I cannot describe it. It is just incredibly painful.
• Onset
• It started about 2 hours ago.
• Precipitating events
• I was out with my husband walking the dog and fell. I do not remember if I fell because of the headache or if the headache came because I hit my head in the fall – it was all so sudden. My husband said I was unconscious for a few seconds but then woke back up.
• Progression/constant/intermittent
• The headache has just been horrible the entire time.
• Previous episodes
• Nothing like this. I had a really bad headache about 2 weeks ago, but it went away on its own.
• Radiation
• It hurts all the way down to my neck.
• Alleviating factors
• If I do not move.
• Aggravating factors
• It gets even worse when I move. And bright lights or loud noises also make it worse.
• Associated symptoms
• I am sick to my stomach and had to throw up once on the way to the hospital.

If a patient tells you that her/his symptoms are aggravated by (bright) light, offer to dim the lights in the examination room.

Review of systems specific to acute severe headache

• Fever/chills
• I was sick with a fever last week, but it seemed like it had gotten better over the past few days.
• Racing of the heart
• Yes.
• Rash/skin changes
• No.
• Chest pain
• No.
• Shortness of breath
• No.
• Recent infections
• I had a sinus infection last week, when I also felt like I was running a fever. It had just gotten better, though.
• Dizziness
• I feel a little lightheaded.
• Numbness
• No.
• Tingling
• No.
• Weakness
• No.
• Vision impaired
• No.
• Seizure
• No.

Past medical history, family history, and social history

• Past medical history
• I have high blood pressure.
• Allergies
• None.
• Medications
• None. I used to take something for my blood pressure, but the prescription ran out a few months ago and I have not had time to renew it.
• Hospitalizations
• Just for the birth of my two children a long time ago.
• Ill contacts
• No.
• Past surgical history
• None.
• Family history
• My mother has migraines and my father also has high blood pressure.
• Work
• I work in sales, at a fashion boutique.
• Home
• I live with my husband and our dog.
• Alcohol
• No.
• Recreational drugs
• Never.
• Tobacco
• No. I no longer smoke.
  • How much before quitting
  • I smoked about 2 packs every day for about 20 years.
• Exercise
• I walk the dog twice a day for about 20 minutes, but that is it.
• Diet
• I would say we have a balanced diet. We eat a lot of vegetables from our own garden.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Palpation of the head
  • Direct fundoscopy
• Cardiovascular examination
  • Auscultation of the heart
• Neurologic examination
  • Assessing level of consciousness
  • Examination of orientation to person, place, and time
    • Patient not oriented to time
  • Focused examination of the cranial nerves
  • Meningism
    • Meningism present
  • Kernig sign
    • Positive
  • Brudzinski sign
    • Positive
  • Focused examination of passive and active motion
  • Focused examination of sensation
  • Focused examination of deep tendon reflexes
  • Focused examination of gait
  • Rapid alternating movement test
  • Finger-to-nose test
  • Babinski sign
  • Romberg test

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered to help the patient lie down.
• Examinee offered to dim the lights in the examination room.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Mrs. Meyers, I understand that you would like to let your husband know where you are. Feel free to give him a call, and he is more than welcome to come into the room if you like. If you cannot get ahold of him, I can ask one of the nurses to page him over the intercom as soon as we are done here. Does that sound okay?”

Patient note

Differential diagnoses

1. Subarachnoid hemorrhage: This patient's acute severe headache, also known as thunderclap headache or described as “the worst headache of my life,” together with her signs of meningeal irritation (i.e., meningism, photophobia, phonophobia, nausea and vomiting, positive Kernig sign and Brudzinski sign) and fever, is highly suggestive of subarachnoid hemorrhage. She also has modifiable risk factors for subarachnoid hemorrhage (i.e., a smoking history and poorly managed hypertension) and likely experienced a sentinel leak headache 2 weeks prior to her current headache.
2. Meningitis: The classic triad of meningitis consists of fever, headache, and meningism, and this patient presents with all three features as well as other signs of meningeal irritation (i.e., photophobia, phonophobia, nausea and vomiting, positive Kernig sign and Brudzinski sign). In addition, sinusitis, which this patient did have, is one of the common causes of ascending bacterial infection that results in meningitis. However, her smoking history and uncontrolled hypertension are risk factors for subarachnoid hemorrhage, which should be ruled out first and more typically presents with the “thunderclap” acute severe headache seen in this case.
3. Hemorrhagic stroke (intracerebral hemorrhage): Acute, intense headache that worsens over time is a symptom of intracerebral hemorrhage, which would also present with nausea, vomiting, and altered mental status. This patient's smoking history and uncontrolled hypertension are risk factors for intracerebral hemorrhage. However, intracerebral hemorrhage typically involves focal neurological deficits and/or seizure, which this patient does not have, and only sometimes presents with the signs of meningeal irritation present in this case, which are more typical of the first two differential diagnoses.

Diagnostic studies

• Noncontrast CT head: best initial test for subarachnoid hemorrhage ; confirmatory test for intracerebral hemorrhage
• CBC: WBCs would be elevated in meningitis. Evaluation of platelet count would be important in consideration of hemorrhagic causes of secondary headache and their operative treatment.
• Glucose, electrolytes: Glucose in serum can be compared with glucose in cerebrospinal fluid following lumbar puncture.
• PT, PTT: to evaluate for coagulation disorders
• Blood cultures: important to take before antibiotic therapy is begun in cases meningitis in order to accurately identify the causative pathogen
• Lumbar puncture with CSF analysis: RBCs, WBCs, and protein are increased in CSF following subarachnoid hemorrhage. Xanthochromia may be present, or a reddish discoloration of the CSF, both of which are due to increased RBCs in the CSF. In meningitis, CSF analysis shows specific patterns of glucose and protein concentration as well as cell count, depending on the causative pathogen (e.g., bacterial, viral, fungal). CT should be performed prior to lumbar puncture if increased intracranial pressure is suspected.
• Angiography: can be used to determine the site of bleeding/aneurysm in subarachnoid hemorrhage and to detect vascular malformations in intracerebral hemorrhage

Other differential diagnoses to consider

• Migraine
• See secondary headache, differential diagnosis of headache, and differential diagnosis of intracranial hemorrhage.