From the Guidelines
The patient's severe, sudden-onset headache with associated neck pain, chills, and nausea warrants urgent medical evaluation for possible subarachnoid hemorrhage or cerebral venous thrombosis, despite the negative CT head without contrast, and I recommend immediate further diagnostic workup with lumbar puncture and imaging studies such as CT angiography or digital subtraction angiography. The patient's symptoms, including a severe headache that started within 30 seconds, neck pain, chills, and nausea, are concerning for a serious neurological condition. According to the Ottawa SAH Rule 1, patients with a severe headache and neck pain or stiffness require additional investigation for subarachnoid hemorrhage. Although the CT head without contrast is negative for intracranial hemorrhage, it is essential to note that CT scans may not always detect subarachnoid hemorrhage, especially if performed early after symptom onset.
- The patient's symptoms, such as bilateral temple headache, neck pain, and nausea, could also be indicative of cerebral venous thrombosis (CVT) 1. CVT is a rare condition that can present with headache, often described as diffuse and progressive in severity over days to weeks. However, a minority of patients may present with thunderclap headache, similar to the patient's presentation.
- Given the high suspicion for subarachnoid hemorrhage or CVT, I recommend immediate administration of pain relief with IV ketorolac 30mg or morphine 4-6mg if pain is severe, along with an antiemetic such as ondansetron 4mg IV for nausea.
- The patient should undergo lumbar puncture to evaluate for subarachnoid hemorrhage or CVT not visible on CT, as well as blood tests including complete blood count, C-reactive protein, and blood cultures.
- Further imaging studies, such as CT angiography or digital subtraction angiography, may be necessary to evaluate for cerebral venous thrombosis or aneurysmal subarachnoid hemorrhage.
- Empiric treatment with antibiotics may be necessary while awaiting results if meningitis is suspected, but the primary focus should be on diagnosing and treating the underlying cause of the patient's symptoms.
From the Research
Clinical Presentation
- The patient presents with a sudden onset of headache, bilateral temples, and lower head pain, with a severity of 10 out of 10.
- Additional symptoms include neck pain, chills, and nausea.
- A CT head without contrast is negative for intracranial hemorrhage.
Possible Diagnosis
- Cerebral venous sinus thrombosis (CVST) is a possible diagnosis, as it can present with sudden onset of headache, nausea, and vomiting 2, 3, 4.
- CVST can also cause intracranial hemorrhage, which may not be detected by a non-contrast CT scan 5.
Risk Factors and Associations
- The use of oral contraceptives is a common risk factor for CVST, particularly in women 4.
- Superior sagittal sinus involvement is associated with a higher risk of bleeding and intracranial hemorrhage 5.
- Older age and multiple concomitant types of hemorrhage are also associated with a higher risk of intracranial hemorrhage 5.
Treatment and Management
- Anticoagulation is the first-line treatment for CVST, even in patients with cerebral hemorrhage or subarachnoid hemorrhage 2, 4.
- Early initiation of therapy and adequate dosing at first dose are important principles in the acute treatment of headache 6.
- Preventive treatment is indicated for frequent headaches, and behavioral strategies should be part of any comprehensive headache management plan 6.