What is the appropriate management for a 20-30 year old male patient presenting with vomiting, severe headache, retroorbital (back of the eyes) pain, diaphoresis (sweating), and neck pain?

Management of Suspected Meningitis in a Young Adult Male

This patient requires immediate emergency department evaluation via ambulance for suspected meningitis—the combination of severe headache, vomiting, neck pain, and retroorbital pain in a 20-30 year old male represents a medical emergency that mandates urgent hospital referral and lumbar puncture consideration. 1

Immediate Action Required

All patients where meningitis is suspected in the community should be referred to hospital for further evaluation and consideration of lumbar puncture (strongly recommended). 1

• Arrange rapid admission to hospital via emergency ambulance so that the patient arrives within an hour of being assessed 1
• This age group (20-30 years) is particularly susceptible to viral meningitis (commonly occurs in adults in their 20s-40s) and meningococcal infection (adolescents and young adults) 1

Critical Clinical Assessment

Document the following features immediately 1:

• Presence or absence of headache (present in this case)
• Altered mental status (assess level of consciousness)
• Neck stiffness (neck pain is present—evaluate for true meningismus)
• Fever (must be documented; note that 30 patients out of 41 with aseptic meningitis were febrile) 2
• Rash of any description (if petechial rash present, Neisseria meningitidis is the causative organism in 92% of cases; however, 37% of meningococcal meningitis patients have no rash) 1
• Seizures
• Signs of shock (hypotension, poor capillary refill time)

Important Clinical Context

The "classic triad" of neck stiffness, fever, and altered consciousness is present in less than 50% of bacterial meningitis cases 1. Individual symptoms like fever, vomiting, headache, and neck stiffness occur frequently in primary care and taken independently are poor discriminators for meningitis—combinations of symptoms are more useful at identifying serious disease 1.

Critical Pitfall to Avoid

Do NOT rely on Kernig's sign or Brudzinski's sign for diagnosis—these have high specificity (up to 95%) but sensitivity can be as low as 5%, making them unreliable for ruling out meningitis 1.

Why This Presentation Demands Urgent Evaluation

This patient's symptom constellation is highly concerning 2:

• Severe headache with vomiting was present in all 41 patients with confirmed aseptic meningitis in one case series, with nausea in 25 patients and vomiting in 23 patients 2
• Retroorbital (back of the eyes) pain with photophobia occurred in 18 of 41 patients with aseptic meningitis 2
• Neck pain/stiff neck was present in 25 of 41 patients with confirmed aseptic meningitis 2
• The headache in aseptic meningitis is typically severe and bilateral (39 of 41 patients), often throbbing in quality (11 of 14 when described) 2

Hospital-Based Diagnostic Workup

Once in the emergency department 1:

• Neuroimaging (CT or MRI brain) should be performed before lumbar puncture if there are focal neurologic findings, decreased level of consciousness, or papilledema 1, 3
• Lumbar puncture is mandatory for definitive diagnosis, looking for increased protein, increased white count, and ruling out bacterial causes 2
• CT of the brain is very sensitive for identifying acute hemorrhage and is considered the gold standard for emergency evaluation 1

Additional Historical Features to Obtain

Before or during transport 1:

• History of travel
• Presence of a source of infection (otitis media or sinusitis)
• Contact with another person with meningitis or sepsis
• Prodromal symptoms (malaise, myalgia, gastrointestinal symptoms occurred in 19 of 41 patients with aseptic meningitis) 2

Why Migraine is NOT the Primary Concern Here

While this presentation could theoretically represent severe migraine with associated symptoms, the combination of severe headache, vomiting, neck pain, and sweating in a young adult male mandates exclusion of life-threatening causes first 1. Meningitis can present with headache that is abrupt in onset or "the worst of the patient's life" (24 of 41 patients), which overlaps with migraine presentations but requires different urgent management 2.

Concern from either the referring doctor or a relative should always be taken seriously, as clinical features are often not clear cut 1. The possibility of rapid deterioration in bacterial meningitis or meningococcal sepsis makes urgent hospital referral mandatory 1.