What is the appropriate management for a 29-year-old female presenting to the Emergency Department (ED) with severe headache, seizure, and neck stiffness, with a history of similar complaints and negative Kernig's (Kernig's sign) and Brudzinski's (Brudzinski's sign) signs?

From the Guidelines

For this 29-year-old female with severe headache, recent seizure, and prior ED visit for similar symptoms with neck stiffness, I would prioritize ruling out subarachnoid hemorrhage (SAH) and meningitis before treating as a migraine. Initial management should include IV Ketorolac (Toradol) 30mg for pain relief, but I would avoid Sumatriptan (Imitrex) until SAH and meningitis are excluded, as it could mask symptoms 1. My workup would include:

• CBC with differential, comprehensive metabolic panel, ESR, CRP, and blood cultures to assess for infection
• Radiologic studies should include a repeat CT head with contrast to evaluate for mass lesions, hemorrhage, or signs of increased intracranial pressure
• Most importantly, I would perform a lumbar puncture to analyze CSF for cell count, protein, glucose, culture, and opening pressure, as this was not done during her previous visit despite concerning symptoms 1 Additional management includes IV fluids, antiemetics like ondansetron 4mg IV for any nausea, and close neurological monitoring. If the LP shows evidence of bacterial meningitis, I would start empiric antibiotics (ceftriaxone 2g IV q12h plus vancomycin 15-20mg/kg IV q8-12h) and consider dexamethasone 10mg IV before or with the first antibiotic dose. The recurrent headache with neck stiffness, new-onset seizure, and constitutional symptoms strongly suggest SAH or meningitis rather than simple migraine, requiring thorough investigation before symptomatic treatment alone 1. It's also important to consider the Ottawa SAH Rule, which suggests that patients with a severe nontraumatic headache reaching maximum intensity within 1 hour, with neck pain or stiffness, witnessed loss of consciousness, onset during exertion, thunderclap headache, or limited neck flexion on examination, require additional investigation for SAH 1.

From the Research

Patient Presentation and Initial Assessment

• The patient is a 29-year-old female presenting with severe headache and seizure, with no history of seizures.
• She has been seen in the ED multiple days ago with similar complaints of headache and neck stiffness, which have worsened.
• The patient denies documented fever but reports chills and hot flashes.
• Negative Kerning and Brudzinski signs are noted.

Differential Diagnosis and Workup

• The patient's presentation suggests a possible secondary headache, given the severity and accompanying symptoms such as neck stiffness and seizure 2, 3.
• Red flag signs and symptoms, including sudden onset of the worst headache, neck stiffness, and seizure, warrant further evaluation for a secondary cause of headache 2, 3.
• Initial workup includes bloodwork and CT head without contrast, which has been performed.
• Consideration for lumbar puncture (LP) is necessary to rule out subarachnoid hemorrhage, especially given the patient's symptoms and the fact that the CT head without contrast may not be sufficient to exclude this diagnosis, particularly if the symptom onset was more than 6 hours prior to presentation 4.

Treatment and Management

• For the patient's migraine headache, treatment with toradol and imitrex may be considered, but this should not delay further workup for secondary causes of headache.
• Given the patient's presentation and the need to rule out serious underlying pathology, a more comprehensive workup including LP and possibly MRI of the brain may be necessary 2, 3.
• It is essential to weigh the risks and benefits of LP, considering the potential for complications, although rare, such as intracranial and intraspinal subarachnoid hemorrhage 5.
• Proper technique and equipment for LP, as well as careful analysis of cerebrospinal fluid, are crucial to minimize risks and obtain accurate diagnostic information 6.

Blood Work and Radiologic Studies

• Blood work should include complete blood count, electrolytes, and inflammatory markers to help identify any underlying infection or inflammatory process.
• Radiologic studies should include a CT head without contrast, which has been done, and consideration for MRI of the brain if the CT is non-diagnostic or if there are ongoing concerns for a secondary cause of headache.
• LP should be performed to analyze cerebrospinal fluid for signs of infection, inflammation, or subarachnoid hemorrhage, keeping in mind the potential risks and the importance of proper technique 4, 6.