What is the most likely diagnosis and appropriate management for a patient who develops a new headache and facial/neck rash after heavy lifting, without focal neurological deficits?

Headache and Rash After Heavy Lifting: Diagnosis and Management

This presentation requires immediate evaluation for subarachnoid hemorrhage (SAH) because the patient meets multiple Ottawa SAH Rule criteria: headache onset during exertion and neck involvement, making SAH a life-threatening possibility that must be ruled out urgently. 1

Primary Diagnostic Concern: Subarachnoid Hemorrhage

Why SAH Must Be Excluded First

The Ottawa SAH Rule mandates additional investigation when patients present with new severe headache and meet ANY of these criteria: 1

• Onset during exertion (present in this case)
• Neck pain or stiffness (neck involvement present)
• Age ≥40 years
• Witnessed loss of consciousness
• Thunderclap headache (instantly peaking pain)
• Limited neck flexion on examination

Headache during physical exertion is specifically recognized as a high-risk feature for aneurysmal SAH, with sentinel headaches occurring in 10-43% of patients within 2-8 weeks before major rupture. 2, 3 Dismissing warning headaches increases the odds of early rebleeding by 10-fold. 3

Critical Imaging Protocol

Obtain non-contrast head CT immediately if presenting within 6 hours of symptom onset—this has 98.7% sensitivity for SAH and misses fewer than 1.5 cases per 1,000 patients. 1 The high early-scan accuracy makes CT the first-line diagnostic test. 4

If CT is negative but clinical suspicion remains high (especially if >6 hours from onset), lumbar puncture for xanthochromia evaluation is mandatory. 1, 4 Spectrophotometric analysis for xanthochromia has 100% sensitivity and 95.2% specificity when performed >6-12 hours after symptom onset. 1

Misdiagnosis of aneurysmal SAH occurs in up to 12% of cases, most commonly due to failure to obtain neuroimaging, and carries a nearly 4-fold higher risk of death or severe disability. 2, 3

Secondary Diagnostic Considerations

Primary Exertional Headache (After SAH Excluded)

If neuroimaging and LP definitively exclude SAH and other structural pathology, consider primary exertional headache (PEH): 5

• Benign, self-limited disorder precipitated specifically by physical exertion
• Frequently comorbid with migraine 5
• Typically bilateral, pulsating, lasting minutes to 48 hours 6, 5
• Responds to indomethacin prophylaxis 7, 5

However, the presence of rash is NOT typical of primary exertional headache and requires separate evaluation. 6, 8

The Rash Component

The facial/neck rash requires independent assessment: 1

• Petechial rash with headache could indicate meningitis or other infectious/inflammatory processes
• Erythematous rash may represent exertional flushing, contact dermatitis, or unrelated dermatologic condition
• Rash distribution and characteristics should be documented carefully

The European Position Paper on Rhinosinusitis notes that facial pain with rash is not characteristic of primary headache syndromes and warrants consideration of infectious or inflammatory etiologies. 1

Management Algorithm

Immediate Actions (Emergency Department)

1. Perform focused neurological examination looking for: 1

   • Altered mental status
   • Focal neurological deficits
   • Meningismus (neck stiffness, limited flexion)
   • Papilledema on fundoscopy
   • Fever (suggests infection)

2. Obtain non-contrast head CT emergently 1, 4

3. If CT negative and >6 hours from onset OR high clinical suspicion persists: perform LP for xanthochromia 1

4. Document rash characteristics: distribution, morphology, blanching, associated fever 1

If SAH Confirmed

• Immediate neurosurgical consultation for aneurysm securing (clipping or coiling) 2
• Nimodipine 60 mg every 4 hours for 14-21 days if presenting within 96 hours 2
• Transfer to high-volume center (>35 aSAH cases/year) improves outcomes 2

If SAH Excluded and Primary Exertional Headache Diagnosed

• Indomethacin 25-50 mg taken 30-60 minutes before exercise is first-line prophylaxis 7, 5
• Proper warm-up before exercise, adequate hydration, and sleep hygiene 6
• Avoid Valsalva maneuvers during lifting 8, 7
• Beta-blockers may be considered if indomethacin fails 7

Critical Pitfalls to Avoid

Never dismiss exertional headache without neuroimaging—approximately 10% of exertional headaches have organic causes, including SAH, posterior fossa masses, and arteriovenous malformations. 6, 5 The absence of "thunderclap" quality does not exclude SAH, as ruptured aneurysms can occasionally present with less dramatic symptoms (Hunt and Hess Grade 1). 2

The combination of headache with rash is atypical for benign exertional headache and should prompt consideration of infectious etiologies (meningitis, encephalitis) or systemic inflammatory conditions. 1 If fever is present, blood cultures and consideration of empiric antibiotics may be warranted while awaiting LP results.

Do not attribute neck symptoms solely to muscle strain from lifting—neck pain/stiffness is a cardinal feature of SAH and meningitis. 1