What is the appropriate ER workup for a patient presenting with fatigue, body aches, and a persistent severe headache for 5 days?

Emergency Department Workup for Fatigue, Body Aches, and Persistent Severe Headache for 5 Days

The emergency department workup for a patient presenting with fatigue, body aches, and persistent severe headache for 5 days should include neuroimaging with non-contrast head CT, laboratory studies, and consideration of lumbar puncture to rule out serious causes of headache including subarachnoid hemorrhage, cerebral venous thrombosis, and vaccine-induced immune thrombocytopenia and thrombosis.

Initial Assessment

• Evaluate for "red flags" that suggest a secondary headache disorder requiring urgent attention:

  • Sudden onset/thunderclap headache (suggests subarachnoid hemorrhage) 1
  • Headache that worsens when lying down or bending over (suggests increased intracranial pressure) 1
  • New unexplained bruising or bleeding (suggests coagulopathy or VITT) 1
  • Shortness of breath, leg swelling, or persistent abdominal pain (suggests thrombosis) 1
  • Neurological deficits (suggests stroke, hemorrhage, or mass lesion) 1

• Assess timing and progression of symptoms:

  • Onset 5-30 days after COVID-19 vaccination may suggest VITT 1
  • Gradual worsening over 5 days may suggest cerebral venous thrombosis 1
  • Headache unresponsive to simple analgesics is concerning 1

Neuroimaging

• Non-contrast head CT should be performed as the first-line imaging study 1

  • If negative but high suspicion for subarachnoid hemorrhage remains, proceed to lumbar puncture 1
  • If negative but concern for cerebral venous thrombosis, consider CT venography or MR venography 1

• Brain MRI with and without contrast is preferred if available, particularly with persistent headache for 5 days 2

  • Can detect lesions causing both headache and systemic symptoms including tumors, vascular malformations, or inflammatory processes 2

Laboratory Studies

• Complete blood count (CBC) to evaluate for:

  • Thrombocytopenia (may suggest VITT if platelet count <150×10^9/L) 1
  • Elevated white blood cell count (may suggest infection) 2
  • Anemia (may contribute to fatigue and headache) 2

• Coagulation studies:

  • D-dimer (elevated >4000 μg/mL suggests VITT or venous thrombosis) 1
  • PT/INR and PTT to assess for coagulopathy 2

• Basic metabolic panel:

  • Electrolyte abnormalities can cause fatigue and headache 2
  • Renal function assessment 2

• Inflammatory markers:

  • C-reactive protein and ESR to assess for inflammatory conditions 2

• Thyroid function tests:

  • Both hypothyroidism and hyperthyroidism can cause fatigue, muscle aches, and headache 2

• Consider specific tests based on clinical suspicion:

  • Anti-PF4 antibodies if VITT is suspected 1
  • Blood cultures if infection is suspected 2

Lumbar Puncture Considerations

• Indicated if:

  • Negative CT but high suspicion for subarachnoid hemorrhage 1
  • Concern for meningitis or encephalitis 1
  • Concern for increased intracranial pressure 2

• CSF analysis should include:

  • Opening pressure
  • Cell count and differential
  • Protein and glucose
  • Gram stain and culture
  • Xanthochromia evaluation (for subarachnoid hemorrhage) 1

Diagnostic Considerations

Vaccine-Induced Immune Thrombocytopenia and Thrombosis (VITT)

• Consider if patient received COVID-19 vaccination 5-30 days prior to symptom onset 1
• Diagnostic criteria include:
  • Thrombocytopenia (platelet count <150×10^9/L)
  • D-dimer >4000 μg/mL
  • Presence of thrombosis
  • Positive anti-PF4 antibodies 1

Cerebral Venous Thrombosis

• May present with persistent headache for several days 1
• MRI findings include signal loss of affected cortical vein in T2-susceptibility-weighted gradient echo sequences 1
• Digital subtraction angiography is the gold standard for diagnosis 1
• Ipsilateral dural thickening and enhancement may be an early sign 1

Migraine

• Consider if patient has history of similar headaches 1
• Diagnostic criteria include:
  • Headache lasting 4-72 hours
  • Unilateral location, pulsating quality, moderate/severe intensity
  • Aggravation by physical activity
  • Associated nausea/vomiting, photophobia, phonophobia 1

Subarachnoid Hemorrhage

• Classic presentation is sudden-onset, severe headache 1
• Non-contrast head CT within 6 hours of symptom onset is highly sensitive 1
• If CT is negative but clinical suspicion remains high, lumbar puncture is indicated 1

Common Pitfalls to Avoid

• Failing to obtain neuroimaging in a patient with persistent severe headache for 5 days 3
• Relying solely on absence of "thunderclap" onset to rule out serious pathology 4
• Discharging patients without adequate follow-up instructions 3
• Attributing symptoms to viral illness without excluding serious causes 4
• Missing VITT in patients who have received COVID-19 vaccination 1

Treatment Considerations

• Treatment should be directed at the underlying cause
• For primary headache disorders:
  • NSAIDs, triptans, or combination analgesics for acute treatment 5
  • Avoid opioids for headache management 3
  • Consider steroids for status migrainosus 5
• For VITT:
  • Non-heparin based anticoagulants
  • Intravenous immunoglobulin 1
• For cerebral venous thrombosis:
  • Anticoagulation
  • Consider neurosurgical consultation if intracranial hemorrhage is present 1