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Clinical Case 131: the Latent Lover’s Headache

Hi there.  Just back from a great break in beautiful Vanuatu.  Seriously amazing place to visit and explore.  The beauty: death ratio is in balance!

I have a case for you today which has come up a few times recently.  It is certainly something that does occur in the ED, but most GPs deal with this dilemma on a regular basis.  Let us dive right in.

Our patient is a 28 year old chap – lets call him Trent.  Trent works in the local sausage factory as a quality control supervisor.  He is usually fit and healthy with no real family history or chronic problems.  He does a bit of exercise, doesn’t smoke and has a few beers at the weekends.  Trent has recently gotten married and life is sweet.

You are working away in your busy GP rooms – Trent is your next patient.  You last saw him for some travel immunisations prior to his honeymoon.  He is a very infrequent attender to your practice…

Here is how the consult goes:

Dr: Hi Trent, hows things?

T: Well Doc.  I’m OK.  My wife has told me I need to come and ask about this headache I got the other day.  I’m not too worried though…

Dr: tell me about it.

T:  Well its a bit embarrassing.  We were sort of fooling around – you know.  Getting intimate.  And half way through I got this sudden headache.  It was like somebody whacked me over the ear with a cricket bat.  It was really full on! One second I was fine, then I was almost knocked out.  Could hardly think.  I was rolling on the floor in pain for half an hour.  It felt like my  head was gonna explode.  Everything was a bit grey for the rest of the night

Dr: Wow. That sounds bad.  When was this. what happened?

T: Oh it happened 2 nights ago. About 48 hours I guess.  The pain eased off a bit after half an hour, but it was still there when I woke up the next day.  I was feeling rubbish and took the day off work.  It went away over the day – so I didn’t bother going to the ED.  But Sheila thought I should get a check up…. just in case.

                  OK, Freeze it there.

Think about how you would approach this case if you were working in ED and Trent presented immediately after the headache began – say 2 hours.

Now put yourself in a GP clinic 2 days later, he is now essentially asymptomatic, with a normal set of Obs, Neuro exam and really seeking reassurance.

What to do?

Here are my questions for you….

Q1:  Does Trent need a work up for subarachnoid haemorrhage / other malignant brain / vascular problems? i.e.  should he get imaging +/- LP today?

Q2:  Does the fact that he is now well, asymptomatic and alive decrease the odds that he has a SAH?

Q3:  If he told you that the headache started immediately after orgasm, rather than in the earlier phase of coitus, would it change your approach?

And just because I am a nice bloke I will add this image to help you visualise the relative usefulness of the investigations for SAH over time.  BEWARE: this is based on some seriously good and some not so good literature [and the graph may not be entirely to scale!!]

Sensitivity of Ix for SAH vs Time

Sensitivity of Ix for SAH vs Time

Comments

  1. >Trent works in the local sausage factory as a quality control supervisor
    > Well its a bit embarrassing. We were sort of fooling around – you know. Getting intimate. And half way through I got this sudden headache.

    lots of nitrates+viagra=HA?

  2. David Berger says:

    1. Yes.

    2. No.

    3. No. Coital cephalgia is the differential, but it needs to be a diagnosis of exclusion.

  3. Good case mate. Here’s my thoughts.

    Q1. Yes I would CT/LP him today. The story is very good for SAH and CT at 48hrs is not an adequate rule out test. Granted he is young and has no RFs for SAH but we see people in this demographic with aneurismal SAH from time to time.

    Q2 Yes. ..and no. I think the concept of a warning bleed is valid and while he hasn’t yet rebled it’s only been 48hrs so I wouldn’t be too reassured by that. I once saw a 30 something lady who presented with vague visual changed but shd had a classic rhunderclap headache 2-3 weeks ago that someone put down to migraine. She had a negative ct/lp but xanthochromia clears by then and she had such a good story she gog a CTA which showed a large COW aneurism…you don’t forget those cases.

    Q3 is a more difficult question. Certainly you can get a headache with orgasm that mimics SAH but coitus is a classic time for SAH too so if it was the first such headache…I’d do the workup.

    Adam.

  4. Trent. . . Recently married. . Feel like I know this guy.
    1. Definitely. CT and if not helpful LP to follow.
    2. Probably does decrease the chances but not enough to make me sleep easily at the end of my shift.
    3. No.

    I think the more difficult question is the one that presents to the GP 3 weeks later. I posted a similar qu. on Twitter a few weeks back .

  5. Yes, no, no.
    Would work him up for SAH in the ED.
    Likely nitrate induced migraine/headache whether from viagra or sausages.
    SAH ruptures with exertion…
    Or just CTA and be done in place of CT/LP
    That being said, likely benign.

  6. Tricky, but I think yes for the LP at this stage. It really could be SAH and you are still in a diagnostic window that might be helpful.

    • Agree. We teach time cut offs for tests in this situation
      However in reality the test characteristics just fade a bit over time. The -LR of a CT or LP is not as potent as it would have been at 12 hours -- but it doesn’t drop to 1! The results just need to be interpreted in this light. Would be fascinating to see study of late- investigated headaches.
      Does delayed presentation offer some protective element? Darwinian survival ??
      Catch you soon mate. Casey

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