CASE STUDIES 2 CHAPTER 27 THREE PATIENTS,THREE SIMILAR HEADACHES ALAN G. FINKEL,MD Case History I occasionally severe menstrual headache was elicited. After a normal CT scan, spinal tap showed an opening pressure A 36-year-old Mexican citizen, a migrant farm worker in the of 140 mm H2O, with 40 white blood cells (WBCs) and 10 United States for 4 years, was admitted previously to the hos- red blood cells (RBCs). CSF protein and glucose were both pital 1 year prior to the current admission for headache and normal. The patient was admitted to the hospital for obser- papilledema. Findings at that time were consistent with cys- vation and with improvement over 24 hours was sent ticercosis with hydrocephalus, and the patient was treated home. Less than 24 hours later, she complained of a severe, with antibiotics and a ventriculoperitoneal (VP) shunt. Lost throbbing occipital headache with nausea and a feeling of to follow-up, compliance with outpatient antibiotics was not being “confused” when standing. She had slight back pain established, and the patient presented for current admission at the lumbar puncture site. Her headache resolved when with complaints of diplopia, dizziness, and phonophobia. supine. CT scan was unremarkable and a second spinal tap Further questioning revealed positional headache not com- had an opening pressure of 20 mm H2O with 32 WBCs and pletely relieved by recumbency. Additional complaints 1 RBC. Protein was slightly elevated. Headache improved included photophobia, nausea, and an episode of near syn- after intravenous fluid bolus and caffeine sodium benzoate, cope while painting a ceiling. He reported a normal com- but was still present with standing. A blood patch was puted tomography (CT) scan and shunt series 3 months ago. performed at the site of the previous spinal tap with near Examination showed ophthalmoplegia, lower extremity instantaneous resolution of the orthostatic headache. hyperreflexia, and a subtle sensory level to pinprick below cervical vertebra C7. Shunt series showed good continuity, Case History III but the neurosurgery resident was unable to obtain fluid from the shunt reservoir. Spinal tap was attempted, and only A 68-year-old female with a benign past medical history a few drops of fluid could be aspirated. No opening pressure presented with a history of migraine, retinal hemorrhage was recorded. Cerebral spinal fluid (CSF) contained six 1 year ago, and a left hemiplegic transient ischemic mononuclear cells, and a slight increase in protein. The fol- attack 3 months ago. Around that time, she developed a lowing day, magnetic resonance imaging (MRI) of the brain moderate bilateral occipital pain that was present through- showed enhancing meninges and “Chiari malformation.” out the day. Over the course of days, there was a steady MRI of the cervical spine revealed a central syrinx extended worsening of the headache intensity, becoming so severe from the craniocervical junction to thoracic vertebra T1. that she required bedrest. She also complained of true ver- Symptoms improved after replacing the pressure valve on the tigo with head movement and throbbing pain that became VP shunt with a programmable valve at higher-pressure set- excruciating after standing for more than 5 minutes. tings. Diplopia did not improve. Photophobia and, to a lesser extent, phonophobia were present. Her last migraine occurred at the age of 54 years, Case History II associated with visual and sensory aura. Family history was remarkable for the death of a brother from heart attack A 24-year-old graduate student was seen for acute and at age 34 years. Social history included the fact that the severe headache associated with fever. A prior history of patient was a basketball player in her youth. Her neurologic 144 / Advanced Therapy of Headache examination was normal except for date confusion and sepsis. The onset of LPHA within 24 to 48 hours after spinal difficulty with medium-term memory. There were clinical tap is typical, and her accompanying signs of feeling dizzy signs of dehydration. Laboratory tests were remarkable for and confused are nonspecific. The repeated spinal tap reveals a slight elevation of creatinine. MRI showed diffuse improvement in WBCs, although her pressure is low. meningeal enhancement with a left frontal fluid collec- Dural puncture either for testing CSF or as a complica- tion. Attempted spinal taps yielded no fluid. tion of obstetric epidural anesthesia is common in modern medical practice. Operative procedures, including cranial Questions on the Cases and spinal surgery, constitute larger and more directed breaches of dura mater. Failure to reestablish the integrity Please read the questions, try to answer them, and reflect of these vital coverings in the aftermath of such procedures on your answers before reading the author’s discussion. is the assumed etiology of LPHA and the attendant non- specific symptoms of dizziness and nausea. Specific •What do these cases all have in common? How are they changes, including cranial nerve dysfunction, may be a different? result of traction on vascular and neural structures that •What are the causes of postural headache, and how occurs as the brain “sags” under the force of gravity while should they be evaluated? standing. CSF leaks should always be suspected if recent •What are the consequences of low CSF pressure besides surgery has been performed, although the time to onset and headache? duration of LPHA may be misleading, and the headache •Why and how often does a blood patch work, and character may be nondiagnostic. should it be done to prevent low-pressure headache? Although the most frequently published cause of LPHA is obstetric epidural anesthesia, it can occur after spinal tap Case Discussion 32 to 36% of the time, most often in thin females. This fre- quency can be reduced using blunt-tip needles. Eighteen The river running through these three cases is the literal percent of obstetric and 13% of nonobstetric epidural pro- stream of cerebral spinal fluid. The postural/orthostatic, cedures result in symptomatic low CSF pressure. The low-pressure headache (LPHA) links their diverse demo- headache is typically orthostatic, improved with lying graphy and various etiologies. down, and diffuse or occipital. Duration can vary from Our first patient, a male, non–English-speaking days to weeks, and chronic LPHA does occur. worker, suffers from an overshunted obstructive hydro- Since the reasons for which lumbar punctures are per- cephalus, leading to chronically low CSF pressure and a formed are various, it is not clear whether normal CSF, or symptom complex referable to traction on oculomotor, a sloppy, bloody tap predicts a lower incidence of LPHA. trigeminocervical, and vestibulocochlear cranial nerves. Classical teaching states that lying flat for a determined The descent of brain causes complications of the cranio- period of time afterward may prevent the onset of this cervical junction, including a syringomyelia and syncope headache. No preference for position, such as supine vs with neck extension. The main concerns in this patient, prone vs lateral decubitus, is clear from the literature. with whom communication may be less than optimal, is Accepted symptomatic treatments include post-onset blood to rule out continued infection, infarction, or diffuse dis- patch, intravenous caffeine sodium benzoate (500 mg in ease of the central nervous system (CNS). In the emer- 1 liter of 5% dextrose in water (D5W) infused over 1 hour gency room, where an MRI might not be immediately or more), or other forms of caffeine and large fluid available, the first goal is to guarantee the safety of the volumes, and nonspecific analgesics including opioids. patient by checking the continuity of the shunt, rule out Antiemetics should be made available to the patient with shunt infection, and then think through the other possi- significant nausea and vomiting. Further evaluation is not ble causes of headache, cranial nerve dysfunction, and necessary unless the headache and other symptoms persist midcervical spine disease with long tract signs below the beyond 7 to 14 days, at which time an MRI may be diag- lesion. A Chiari malformation with syrinx of the cervical nostic. The minimal CSF pleocytosis in LPHA should not spinal cord, combined with traction on cranial nerves, confuse a more important diagnosis, although caution in ties most of these together. interpretation should always be exercised. Rarely, LPHA Our second case is a young woman with a suggestive may be accompanied by encephalopathy, obtundation, or history of migraine presenting for her “worst” headache even coma. This should be kept in mind when seeing a pro- associated with systemic signs of infection. The astute clin- gressively ill patient with encephalopathy, since some ician immediately attempts to rule out meningitis, and inflammatory and infectious conditions including herpes upon finding normal pressure and suggestive spinal fluid, simplex virus encephalitis may present with an initially the patient is admitted until fluid analysis confirms no normal or traumatic CSF. Three Patients, Three Similar Headaches / 145 If our first two cases are the headwaters and upper B. Headache that occurs or worsens less than 15 minutes stream of intracranial hypotension, then the last is the after assuming the upright position and disappears or rapids. A confusing history of earlier life migraine, vascu- improves less than 30 minutes after assuming the lar events from both large and small vessels, and slowly recumbent position progressive mild dementia would not usually be what we The IHS also included 7.2.1 postlumbar puncture would associate with low CSF pressure. Where the other headache, and 7.2.2 posttraumatic, postoperative, or idio- two patients have clear precipitants for low pressure, this pathic cerebrospinal fluid leak. third patient does not. Recent reports of spontaneous The newer (2004) IHS classification for headache intracranial hypotension (SIH) have revealed comorbidi- attributed to low pressure is outlined in Appendix 27-1; ties with connective tissue disorders and diverse presen- however, the principles of diagnosis are the same, with tations including reversible frontal lobe dementias.