What to do for a patient presenting with a severe headache suspected to be due to meningitis?

Management of Severe Headache in Suspected Meningitis

Immediately stabilize the patient's airway, breathing, and circulation, obtain blood cultures within 1 hour, and administer empiric antibiotics within 1 hour—either immediately after lumbar puncture in stable patients or immediately after blood cultures in those with sepsis or shock. 1

Immediate Priorities (First Hour)

Stabilization and Assessment

• Assess and stabilize ABCs (airway, breathing, circulation) as the immediate priority 1
• Document Glasgow Coma Scale score for prognostic value and to monitor for deterioration 1
• Arrange urgent senior clinician review within the first hour—patients can deteriorate rapidly despite initially reassuring vital signs 1
• Consider ICU admission if National Early Warning Score ≥7 or if signs of shock are present 1

Critical Diagnostic Steps

• Obtain blood cultures within 1 hour of hospital arrival, before antibiotics if possible 1, 2
• Send blood for pneumococcal and meningococcal PCR (EDTA sample), glucose, lactate, and procalcitonin if available 1
• Perform full blood count, renal function, liver function, and coagulation studies 1

Decision Algorithm for Lumbar Puncture and Antibiotics

For Patients WITHOUT Sepsis/Shock (Meningitis Predominant)

• Perform lumbar puncture within 1 hour if safe to do so 1
• Start antibiotics immediately after LP is completed, within the first hour 1
• If LP cannot be performed within 1 hour, start antibiotics immediately after blood cultures and perform LP as soon as possible afterward 1

For Patients WITH Sepsis/Shock or Rapidly Evolving Rash

• Give antibiotics immediately after blood cultures—do NOT delay for LP 1, 2
• Start fluid resuscitation immediately with 500 ml crystalloid bolus 1
• Follow Surviving Sepsis guidelines for ongoing resuscitation 1
• Do NOT perform LP at this time 1

Contraindications to Immediate LP (Require CT First)

Defer LP and obtain neuroimaging if any of the following are present: 1

• Focal neurological signs
• Papilledema
• Continuous or uncontrolled seizures
• Glasgow Coma Scale ≤12

Important caveat: Inability to visualize the fundus is NOT a contraindication to LP, especially with short symptom duration 1

Empiric Antibiotic Therapy

Hospital Setting

• Ceftriaxone or cefotaxime are first-line choices due to excellent CSF penetration in inflamed meninges 1
• Ceftriaxone is indicated for meningitis caused by Haemophilus influenzae, Neisseria meningitidis, or Streptococcus pneumoniae 3
• For confirmed meningococcal meningitis, add dexamethasone 0.15 mg/kg every 6 hours (but NOT for meningococcal septicemia) 2

Pre-Hospital/Community Setting

• Benzylpenicillin, cefotaxime, or ceftriaxone can be given intramuscularly if IV access unavailable 1
• Do NOT delay hospital admission to give antibiotics in the community 1
• If known anaphylaxis to beta-lactams, delay treatment until hospital arrival when alternative antibiotics can be given 1

Headache-Specific Management

Acute Phase

• Analgesics such as acetaminophen and NSAIDs for headache relief 4
• Ensure adequate hydration and rest 4
• The severe headache itself is a symptom requiring urgent diagnostic workup, not isolated symptomatic treatment 5

Important Clinical Context

• All patients with aseptic/viral meningitis have headache, typically severe and bilateral 5
• Headache is often throbbing in quality and may be of abrupt onset or "worst ever" 5
• Severe headache that worsens or is abrupt in onset could indicate bacterial meningitis, viral meningitis, or subarachnoid hemorrhage—all require urgent evaluation 5

Monitoring and Resuscitation Endpoints (If Septic Shock Present)

Target the following endpoints: 1

• Capillary refill time <2 seconds
• Mean blood pressure >65 mmHg
• Urine output >0.5 ml/kg/hour (requires urinary catheter)
• Normal mental status
• Lactate <2 mmol/L
• Warm extremities with equal peripheral and central pulses

Critical Pitfalls to Avoid

• The classic triad of fever, neck stiffness, and altered consciousness is present in <50% of bacterial meningitis cases—do not rely on it 2, 6
• Kernig's and Brudzinski's signs have very low sensitivity (as low as 5%) and should NOT be relied upon for diagnosis 1, 2
• Elderly patients often present atypically with altered mental status rather than fever or neck stiffness 1, 2
• Never delay antibiotics for neuroimaging or LP in suspected bacterial meningitis with sepsis 1, 2
• Only 63% of patients with meningococcal meningitis have a rash, so absence of rash does not exclude the diagnosis 2
• Patients can deteriorate rapidly even with initially normal vital signs—maintain high vigilance 1

Post-Acute and Discharge Considerations

Expected Recovery Issues

• Fatigue, sleep disorders, and emotional difficulties are frequently reported for weeks to months after discharge 4, 6
• Many patients cannot immediately return to normal activities despite feeling well at discharge 4, 6
• Support staged return to work or studies on a part-time basis initially 4

Follow-Up

• Assess for long-term sequelae before discharge 2
• Perform hearing tests if hearing may have been affected 2
• Monitor for cognitive deficits, learning impairment, and potential post-traumatic stress disorder 2
• Consider early referral to mental health services if emotional difficulties develop 4