Migraine or not?

UNFINISHED CASE: COME BACK LATER 

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History of Present Illness:

• A 42-year-old female with a history of chronic migraine headaches presents to the ED for headache. She states this headache is different than her normal migraine.  It was more rapid onset with vomiting earlier in the course than usual for her.  The location of the pain is also atypical for her.
• She states the pain is frontal and occipital. She has had 2 episodes of nonbilious, nonbloody emesis.
• She denies any difficulty with speech, swallowing, or ambulation, fever, abdominal pain or other complaints

Vital Signs & Physical Exam:

• Vital signs are normal except for.
• Physical exam is normal except for some mild meningismus and some photophobia

Initial Differential Diagnosis:

• Migraine
• Posterior circulation stroke (often similar but not same as a prior migraine)
• Meningitis
• Spinal epidural abscess
• Cerebral Aneurysm

Initial Diagnostic Testing:

• CBC and BMP are normal
• The CT is shown below

QUESTIONS:

1. What does the case image show?  (click two times to enlarge)
2. What should you do next?  
3. Where can one get a quick refresher on this topic?  

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ANSWERS:

1. What does the case image image show?  The image shows a large subarachnoid bleed.
2. What should you do next?  Call neurosurgery and consider the following:  See case conclusion below tutorial page-shot.
3. Where can one get a quick refresher on this topic?  See yellow highlighted area below from purple book above…

1-Minute Consult on the EM topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: ED treatment: more pain medication, antiemetics, Keppra, head of the bed at 30°, frequent neuro checks, Nimotop, additional antihypertensive therapy prn, CT angiogram of the circle of Willis in order to determine whether or not the patient would benefit from coiling.