Headaches Presenting in the Emergency Department (Continued)

Carotid or vertebral arterial dissection may also occur after trauma. These often manifest as a unilateral headache, with or without neck pain, and may be associated with focal neurologic signs, such as Horner syndrome (ptosis and miosis unilaterally).

Local injury to neck structures, including cervical vertebra or disks, can create a referred headache with associated neck pain. Head trauma may be followed by the development of a postconcussive syndrome, and headaches may be accompanied by dizziness, fatigue, irritability, anxiety, insomnia, and decreased concentration.

INTRACRANIAL INFECTION

Meningitis or meningoencephalitis must be suspected in any patient with new headache accompanied by neck stiffness or fever, nausea/vomiting, and photophobia, mimicking a severe migraine. In addition to a lumbar puncture, blood cultures are drawn and antibiotics started empirically when bacterial meningitis is suspected. Patients with focal neurologic findings, papilledema, or altered mentation must have a CT or MRI before lumbar puncture, to exclude a brain abscess with associated mass effect. In a patient with a new headache associated with altered mentation or seizure, rapid initiation of acyclovir is recommended to cover for herpes simplex virus (HSV) while results of diagnostic testing are pending. The details on diagnosis and evaluation of intracranial infection are outlined in Section 11.

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