From the Guidelines
For a 25-year-old with seizure history presenting to the ER with acute headache, I strongly recommend immediate neurological evaluation including head CT or MRI to rule out intracranial pathology, as the most recent and highest quality study 1 emphasizes the importance of prompt diagnosis and treatment in such cases. The patient should receive appropriate pain management with acetaminophen 1000mg or ibuprofen 400-600mg, avoiding opioids if possible as they may mask neurological symptoms.
- A complete neurological examination, seizure history review, and medication compliance check are essential.
- Laboratory tests should include complete blood count, comprehensive metabolic panel, and anticonvulsant drug levels if the patient is on such medications.
- If the headache represents a different pattern from previous episodes or is accompanied by concerning symptoms like fever, altered mental status, or focal neurological deficits, more urgent intervention may be needed. The patient's seizure medication should be continued without interruption, and if subtherapeutic levels are found, appropriate adjustments should be made. This comprehensive approach is necessary because headaches in patients with seizure disorders may represent breakthrough seizures, medication side effects, post-ictal phenomena, or unrelated but serious conditions like subarachnoid hemorrhage or meningitis, as highlighted in 1 and 1. Close follow-up with the patient's neurologist within 1-2 weeks is recommended regardless of ER findings, as suggested by 1. The Ottawa SAH Rule, as outlined in 1, can be used to identify patients who require additional investigation for subarachnoid hemorrhage, and a high index of suspicion is warranted in patients with seizure history presenting with acute headache. Noncontrast head CT remains the cornerstone of diagnosis of subarachnoid hemorrhage, and its sensitivity is very high, especially when interpreted by fellowship-trained, board-certified neuroradiologists, as noted in 1. Magnetic resonance imaging (MRI) can be used to obtain more information about the brain and to search for other causes of subarachnoid hemorrhage, but its practical limitations, such as routine availability and logistics, limit its use in the emergency setting, as discussed in 1 and 1.
From the Research
ER Evaluation of Acute Headache in 25-Year-Old with Seizure History
- The patient's history of seizures is crucial in the ER evaluation, as it may indicate a potential cause of the acute headache 2.
- The risk of a second seizure is about 36% at 2 years and 46% after 5 years, and this risk is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma 2.
- In the ER, the patient should be evaluated for potential causes of the headache, including subarachnoid hemorrhage (SAH), which can be diagnosed using CT scans 3.
- However, pseudo SAH can also be present, which is an entity defined when characteristic CT findings of SAH are seen without evidence of hemorrhage on MRI, autopsy, or cerebrospinal fluid analysis 4.
- The patient's seizure history and acute headache may also be related to other conditions, such as bacterial meningitis, which can present with similar symptoms 4.
Diagnostic Considerations
- CT evaluation of subarachnoid hemorrhage is a practical review for the radiologist interpreting emergency room studies, and it is essential to consider the sensitivity of CT for detection of SAH 3.
- The differential diagnosis of SAH not due to aneurysmal rupture should also be considered, and other potential causes of the patient's symptoms should be evaluated 3.
- The role of LSD1 in pro-inflammatory polarization of macrophages may not be directly relevant to the patient's acute headache and seizure history, but it highlights the importance of considering the underlying mechanisms of inflammation and immune response in the diagnosis and treatment of neurological conditions 5.