What is the appropriate initial management for a 16-year-old male who developed a new persistent headache and facial/neck rash 24 hours after heavy weight‑lifting, without focal neurological deficits?

Exertional Headache with Facial/Neck Rash in an Adolescent: Initial Management

This 16-year-old male requires urgent evaluation to exclude subarachnoid hemorrhage (SAH), which can present with exertional headache and facial/neck petechiae from Valsalva-induced venous congestion, though the absence of focal neurological deficits is reassuring. 1

Immediate Assessment and Red Flag Evaluation

The clinical presentation warrants urgent investigation because:

• Exertional onset is a mandatory criterion for additional SAH investigation according to the American Heart Association, as exertional headache can represent SAH or sentinel bleed 1
• The facial/neck rash likely represents petechiae or facial plethora from Valsalva maneuver during heavy lifting, which increases intrathoracic pressure and causes venous congestion 1
• However, this presentation pattern does not exclude intracranial pathology and requires imaging 1

Critical Red Flags to Assess

Evaluate for the following high-risk features:

• "Thunderclap" quality (instantly peaking pain reaching maximal intensity within 1 hour) - present in 80% of SAH cases 2
• Neck stiffness or nuchal rigidity - present in 35% of SAH cases 2
• Brief loss of consciousness - occurred in 53% of SAH cases 2
• Nausea/vomiting - present in 77% of SAH cases 2
• Photophobia or altered mental status 2
• Any focal neurological deficits including cranial nerve palsies 2

Diagnostic Workup Algorithm

First-Line Imaging (Within 6 Hours of Onset)

Non-contrast head CT is the initial diagnostic test of choice 3:

• Sensitivity is 98.7% when performed within 6 hours of headache onset and interpreted by a fellowship-trained neuroradiologist 2, 1
• CT remains highly sensitive (close to 100%) in the first 3 days, declining to 93% at 24 hours 2
• CT is superior to MRI for detecting acute SAH (98% sensitivity, 99% specificity) and is faster, requiring no sedation in adolescents 3

If CT is Negative but Clinical Suspicion Persists

• Lumbar puncture for xanthochromia should be performed >6-12 hours after symptom onset (sensitivity 100%, specificity 95.2%) 2, 1
• CT angiography may be indicated if vascular pathology remains a concern despite negative initial workup 1

Neuroimaging Indications in Adolescents

The ACR Appropriateness Criteria for pediatric headache support imaging in this case because 3:

• Exertional onset is a high-risk feature
• New-onset severe headache in an adolescent warrants evaluation
• The yield of neuroimaging is low in primary headaches but increases substantially with red flag features 3

Alternative Diagnoses to Consider

If imaging is negative and the patient remains neurologically intact:

Benign Exertional Headache with Valsalva-Induced Petechiae

This is the most likely diagnosis if workup is negative 1:

• The facial/neck rash represents petechiae from increased venous pressure during heavy lifting
• Headache results from transient intracranial pressure changes during Valsalva maneuver
• Management includes avoiding triggering activities, gradual return to exercise, and NSAIDs for symptomatic relief 4

Primary Exertional Headache

• Occurs during or after physical exertion
• Typically bilateral but can be unilateral
• Lasts minutes to 48 hours
• Diagnosis of exclusion requiring negative neuroimaging 1

Migraine Triggered by Exertion

• If headache meets ICHD-3 criteria for migraine, consider acute treatment with NSAIDs or triptans 1
• Prophylaxis may be needed if attacks become frequent 1

Management Based on Imaging Results

If CT Shows Abnormality

• Immediate neurosurgical consultation 2
• Maintain systolic BP <160 mmHg using titratable agents (nicardipine, labetalol) to prevent rebleeding 2
• Nimodipine 60 mg every 4 hours for 21 days if SAH is confirmed 2
• Transfer to high-volume center with neurocritical care services 2

If CT is Normal and Patient is Neurologically Intact

• Observation for 24 hours is appropriate for neurologically intact children with minor head injury, even with CT abnormalities 5
• Discharge with return precautions if patient remains stable and has reliable follow-up 5
• Avoid strenuous activity for 1-2 weeks 3
• Follow-up within 24-48 hours with primary care or neurology 6

Common Pitfalls to Avoid

• Never assume new exertional headache is benign without proper imaging - missing SAH carries catastrophic consequences 1
• Do not rely solely on absence of neurological deficits to exclude serious pathology - 6 patients with GCS 15 in one study required neurosurgical intervention 7
• Do not dismiss the rash as purely dermatologic - it may represent Valsalva-induced petechiae but requires correlation with imaging findings
• Avoid premature discharge before completing appropriate workup, as rebleeding risk is highest in first 24 hours (3-4%) 2

Disposition and Follow-Up

• Emergency department observation unit is appropriate for neurologically intact patients pending imaging results 5
• 89% of similar patients are discharged within 24 hours with good outcomes 5
• Provide written discharge instructions including return precautions for worsening headache, vomiting, altered mental status, or new neurological symptoms 7
• Arrange outpatient follow-up within 24-48 hours to reassess symptoms and review imaging 6