Hot Seat Case # 108: 17 year old male with an intractable headache
Posted on: February 27, 2018, by : Daniella Santiago-Haddock
Daniella Santiago-Haddock, MD Inova Children’s Hospital
with Sephora Morrison, MD Children’s National Medical Center
17 y/o male with no previous medical history who presents with several weeks of persistent headache. He was seen at our ED at onset of symptoms and discharged home with the diagnosis of likely migraine headache, after improving with symptomatic treatment. After discharge, parents state that he still persisted with symptoms, for which he was seen at a Headache speciality clinic. Migraine headaches were confirmed and advised home protocol for symptomatic treatment including sumatriptan, NSAID’s, muscle relaxants, and vitamin supplements. Head CT ordered as outpatient after CNMC visit was negative (parents have CD and report). On the day of arrival, the headache was getting worse, and not responding to NSAID’s or sumatriptan. He admits non-compliance both pharmacologically and non-pharmacologically.
ROS: Negative for fever, chills, weight loss. No blurry vision, vision loss, dizziness, ataxia. He does endorse sensitivity to light and noise, as well as neck pain. No numbness or tingling. No hx of trauma or injuries. No recent travels or illness
Vital signs: T:98.7 HR:85 BP:110/70 RR:14 O2:100%
General: Awake, alert, uncomfortable appearing but non-toxic. Talking with parents
Head: Atraumatic head, some frontal and occipital scalp tenderness but no swelling or crepitus
Eyes: PERRL, EOMI
Ears/nose/throat: Normal TM’s bilaterally, no effusions. MMM, no pooling secretions or exudates
Neck: supple, full ROM. no LAD. Some upper trapezius tenderness present bilaterally
Heart/Lungs: RRR, strong pulses, lungs CTA bilaterally
Neuro: cranial nerves grossly intact. strength 5/5 throughout. no subjective numbness or tingling. able to ambulate without difficulty. negative Romberg
You begin symptomatic treatment with IV migraine medications.
Upon reevaluation the patient states that he has only had minimal improvement. You follow your migraine protocol and give IV Valproic acid, with minimal improvement. As you are calling upstairs to admit the patient for DHE, nursing staff notifies you that the patient is acting “weird”. When you go to reassess, he is now refusing to speak in English and only talking in his native language. He is also only shaking his head for yes/no questions and not wanting to make eye contact or engage. Remainder of the exam is still grossly normal.
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I would pursue a more thorough workup given the patient’s change in mental status – no longer willing to speak in English progressing to only giving yes/no responses and avoiding eye contact seems very altered for a 17-year-old. It doesn’t sound like he has the classic signs of extrapyramidal symptoms associated with compazine – dystonia, akithisia, tremor, tardive dyskinesia, etc.
I think it’s unlikely that he has an acute mass effect given a recent normal head CT; however, one of the prospective studies looking at the likelihood of intracranial abnormalities prior to obtaining an LP (https://www.ncbi.nlm.nih.gov/pubmed/11742046) showed that, in addition to age > 60 years, immunocompromise, h/o CNS disease, and h/o recent seizure, the following features might be associated with increased likelihood of head CT abnormalities: an abnormal level of consciousness (check!), an inability to answer two consecutive questions correctly or to follow two consecutive commands (maybe), gaze palsy (maybe), abnormal visual fields (maybe), facial palsy (no), arm drift (no), leg drift (no), and abnormal language (check!).
Then a question becomes whether or not the patient is too altered to tolerate a head CT. It should only take 10-15 minutes, but will he require anxiolysis? I would hesitate to further alter his mental status by giving Ativan or Versed, but it might be necessary to keep him still for the duration of the imaging study. What agents would people choose to use?
Great comments from Sam.
It’s always stressful when anxiolysis takes longer to achieve than the actual scan. (You’d laugh at our history with choral hydrate back when dinosaurs ruled the earth). While not as suspicious of a mass effect, hemorrhage, hydrocephalus or abscess are still on the differential for altered mental status with sudden onset.
I might start with a short acting benzo. If he were completely uncooperative and/or combative and at risk to self or others then you have to consider chemical and physical restraint if distraction doesn’t work (autism?) I might consider ketamine or haldol(not as keen)vs RSI in the worst case scenario. We need his scan.