360 Emergency Medicine
Diazepam(a)is useful for treating cervical muscle spasm and torticollis.
At high doses, it has the principle side effect of respiratory depression. It is
unlikely to relieve the pain associated with a migraine although it may be
useful for associated scalp and trapezius spasm. High flow oxygen (b)is ben-
eficial to migraine patients but is not the mainstay of treatment. Other adjuncts
to pharmacotherapy include decreasing ambient light and noise and putting a
cool cloth over the forehead. Acetaminophen (d)is a useful first-line treatment
with NSAIDs for migraine and tension-type headaches. They represent a safer
first-line treatment to triptans, which are contraindicated in patients with dys-
rhythmias, poorly controlled hypertension, or coronary artery disease. Thera-
peutic removal of CSF (e)is indicated in cases of IIH.
325.The answer is d.(Rosen, p 1464. Candido, pp 451-469.)The patient has
apost-LP headache.The headache is thought to be caused by the removal of
CSF during LP with a continued leakage of CSF. It is exquisitely sensitive to
positionand many patients will experience complete relief of pain after being
placed in Trendelenburg position. A blood patchis placed by injecting an
aliquot of the patient’s blood in a sterile fashion just external to the dura mater
at the same interspace where the LP occurred. The majority of patients have
relief of symptoms with this procedure. Prevention of the post-LP headache
includes using a 22-gauge or smaller needle, removing as little fluid as possible,
and facing the bevel up when the patient is in the lateral position.
Administering IV fluids (a)is thought to increase intravascular volume
and CSF production, thereby reducing symptoms. It should be adminis-
tered to this individual; however, it is not definitive treatment. Standard
migraine treatments (b)are often ineffective in treating the post-LP headache.
The headache often responds well to caffeine-based therapy. Meclizine (c)is a
medication used to treat peripheral vertigo and is ineffective in the treat-
ment of the post-LP headache. Repeat LP (e)is unlikely to yield new diag-
nostic information and is likely to exacerbate the headache. Headaches that
improve after dural puncture are those typically associated with IIH. There
are case reports of spontaneous subdural hematoma post-LP caused by rel-
ative descent of the brain in the setting of decreased CSF with stretch on
bridging veins. If this is a diagnostic consideration, a head CT scan should
be obtained.
326.The answer is d.(Goetz, pp 1797-1798.)IIHformerlypseudotumor
cerebri,requires urgent treatment when there is a history of visual phe-
nomena, particularly transient vision loss. Agents used to lower ICP in this