What is the next step for managing a severe headache in a patient with a cerebellar infarct, who has not responded to intravenous (IV) tramadol (opioid analgesic)?

Immediate Neurosurgical Evaluation for Possible Decompressive Surgery

This patient requires urgent neurosurgical consultation to evaluate for suboccipital decompressive craniectomy, as severe persistent headache in the setting of acute cerebellar infarction may indicate evolving mass effect with risk of brainstem compression and herniation.

Critical Clinical Context

This is not a primary headache disorder—this is headache secondary to acute cerebellar stroke with concerning features:

• Severe, persistent headache (8/10) despite IV analgesics in the context of bilateral cerebellar infarction suggests possible evolving mass effect 1
• The right-greater-than-left distribution increases risk of significant edema and fourth ventricle compression 1
• Cerebellar infarcts can deteriorate rapidly due to edema peaking at 24-72 hours post-stroke, leading to obstructive hydrocephalus, brainstem compression, and herniation 1
• Intact consciousness does not exclude evolving mass effect—clinical deterioration can occur suddenly 1

Immediate Management Algorithm

Step 1: Urgent Repeat Neuroimaging

• Obtain immediate repeat MRI brain or CT head to assess for:
  • Cerebellar edema progression
  • Fourth ventricle compression or displacement
  • Obstructive hydrocephalus
  • Effacement of perimesencephalic cisterns 1

Step 2: Neurosurgical Consultation

• Contact neurosurgery immediately if imaging shows any of the above features 1
• Suboccipital decompressive craniectomy with duroplasty can be life-saving when performed before clinical deterioration 1
• Timely surgical intervention significantly increases survival in space-occupying cerebellar infarcts 1

Step 3: Optimize Medical Management While Awaiting Evaluation

For headache control (while monitoring for deterioration):

• Switch from tramadol to IV ketorolac 30 mg (if age <65 and no renal impairment/GI bleeding history) plus IV metoclopramide 10 mg 2

  • This combination provides superior analgesia compared to opioids for severe headache 2
  • Ketorolac has minimal risk of rebound headache and provides 6 hours of duration 2
  • Metoclopramide provides synergistic analgesia beyond its antiemetic effect 2

• Alternative: IV prochlorperazine 10 mg if metoclopramide is contraindicated 2

  • Comparable efficacy to metoclopramide with favorable side effect profile 2

• Avoid continuing opioids (tramadol), as they have limited evidence for headache efficacy and risk dependency and rebound headache 3, 2

Step 4: Discontinue Mannitol if No Longer Indicated

• Reassess need for continued mannitol after 5 days—prolonged use without clear indication of elevated intracranial pressure may not be beneficial 1
• If mass effect is confirmed on repeat imaging, continue osmotic therapy under neurosurgical guidance 1

Critical Pitfalls to Avoid

• Do not attribute severe persistent headache to "expected post-stroke pain" without excluding evolving mass effect—this can be fatal 1
• Do not continue escalating analgesics without repeat imaging in cerebellar stroke with severe headache 1
• Do not delay neurosurgical consultation waiting for neurological deterioration—by the time consciousness declines, surgical outcomes are significantly worse 1
• Do not use IV corticosteroids for headache control—they are not effective for acute headache and not indicated in acute ischemic stroke 3

Monitoring Parameters

• Neurological checks every 2-4 hours for:
  • Level of consciousness
  • Cranial nerve function (especially VI nerve palsy suggesting increased ICP)
  • Gait and coordination (further deterioration)
  • New nausea/vomiting (suggesting increased ICP) 1