In a 31‑year‑old female with severe headache and neck pain refractory to opioid analgesia, what are the likely differential diagnoses and what is the recommended acute management plan?

Severe Headache with Neck Pain Refractory to Opioids in a 31-Year-Old Female

Immediate Priority: Rule Out Life-Threatening Secondary Causes

This presentation demands urgent evaluation for subarachnoid hemorrhage, meningitis, or arterial dissection before considering primary headache disorders. The combination of severe headache, neck pain, and failure to respond to opioids raises critical red flags that cannot be dismissed. 1

Red Flag Assessment

This patient meets multiple Ottawa SAH Rule criteria that mandate investigation for subarachnoid hemorrhage:

• Neck pain or stiffness is a cardinal red flag for both subarachnoid hemorrhage and meningitis 1, 2
• Severe headache refractory to standard analgesia suggests serious underlying pathology 1
• The combination of headache with neck pain carries a 73-90% association with serious secondary causes in acute presentations 3

Immediate Diagnostic Workup

Non-contrast head CT must be performed immediately if the patient presents within 6 hours of symptom onset (98.7% sensitive for subarachnoid hemorrhage). 1

If CT is negative or the patient presents >6 hours from onset, lumbar puncture for xanthochromia is mandatory (100% sensitivity, 95.2% specificity when performed >6 hours after symptom onset). 1

Physical examination must specifically assess for:

• Neck stiffness (resistance to passive neck flexion) indicating meningitis or subarachnoid hemorrhage 1, 4
• Focal neurological deficits (likelihood ratio 5.3 for serious intracranial pathology) 1
• Fever suggesting infectious etiology such as meningitis 1, 4
• Papilledema on fundoscopy indicating raised intracranial pressure 1
• Altered consciousness or impaired memory signaling secondary causes 1

Differential Diagnosis (in order of urgency)

Life-threatening causes requiring immediate intervention:

1. Subarachnoid hemorrhage – accounts for 22.9% of fatal headache presentations, commonly presents with neck pain, occipital headache, and loss of consciousness 2
2. Bacterial meningitis – fever with neck stiffness is pathognomonic 1, 4
3. Arterial dissection (carotid or vertebral) – severe unilateral neck pain with headache 5
4. Intracranial hemorrhage – vascular events account for 60.4% of fatal headache cases 2

Other secondary causes: 5. Intracranial mass lesion – primary brain tumors/cysts account for 16.7% of fatal headache presentations 2 6. Cerebral venous sinus thrombosis – progressive headache with focal deficits 1

Primary headache disorders (only after excluding secondary causes): 7. Cervicogenic headache – unilateral pain spreading from posterior to frontal regions, triggered by neck movements, with digital pressure over upper nuchal area reproducing pain 6 8. Migraine with prominent neck pain – 73-90% of migraine patients experience comorbid neck pain 3 9. Tension-type headache – affects 38% of population but rarely presents with severe refractory pain 7

Management Algorithm

Phase 1: Emergency Stabilization (First 30 Minutes)

Obtain vital signs immediately to assess for fever (meningitis), hypertension (intracranial hemorrhage), or hypotension (shock). 1

Perform focused neurological examination looking specifically for the red flags listed above. 1, 4

Order non-contrast head CT stat if any red flag is present. 1

Phase 2: Acute Pain Management (While Awaiting Imaging)

Opioids are contraindicated and ineffective for primary headache disorders – their failure in this case actually supports a secondary cause or suggests medication-overuse headache if used chronically. 8

First-line IV therapy for severe headache:

• Metoclopramide 10 mg IV provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic properties 8
• Ketorolac 30 mg IV (if no contraindications: renal impairment, GI bleeding history, uncontrolled hypertension) for rapid onset and 6-hour duration 8
• Prochlorperazine 10 mg IV as alternative to metoclopramide with comparable efficacy 8

Alternative if triptans/NSAIDs contraindicated:

• Dihydroergotamine (DHE) 0.5-1.0 mg IV can be repeated hourly up to 2 mg/day, but is contraindicated with concurrent beta-blockers, uncontrolled hypertension, coronary artery disease, or pregnancy 8

Phase 3: Post-Imaging Management

If imaging reveals secondary cause:

• Neurosurgical consultation for subarachnoid hemorrhage or mass lesion
• Infectious disease consultation and empiric antibiotics for meningitis
• Vascular neurology consultation for arterial dissection

If imaging is negative and lumbar puncture is negative:

• Consider cervicogenic headache: assess for reproducible pain with digital pressure over C2-C3 facet joints and upper nuchal area 6
• Trial of physical therapy and cervical nerve blocks if cervicogenic headache is suspected 6
• Consider migraine prophylaxis if headaches are frequent (≥2 attacks/month with ≥3 days disability) 8

Critical Pitfalls to Avoid

Never assume severe headache with neck pain is benign without proper imaging – missing subarachnoid hemorrhage carries catastrophic consequences. 5

Do not rely solely on neuroimaging without considering the complete clinical picture – normal imaging does not exclude meningitis or early arterial dissection. 1

Avoid continuing opioid therapy – opioids have no role in primary headache management and create medication-overuse headache, dependency, and rebound headaches. 8

Do not discharge without clear red-flag return precautions including worsening to "worst headache of life," seizure activity, loss of consciousness, or new focal deficits. 1

Medication Frequency Limits (If Primary Headache Confirmed)

Strictly limit all acute medications to ≤2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 8

If acute treatment is needed >2 days/week, initiate preventive therapy immediately with propranolol 80-240 mg/day, topiramate, or amitriptyline 30-150 mg/day. 8