366 Emergency Medicine
with close follow-up. These patients must be reliable for follow-up, not
immunocompromised and otherwise well-appearing. They should be told
to return for reevaluation if their symptoms do not improve within 48 hours.
If they have not improved, reevaluationincludingneuroimaging, repeat
LP,and treatment with antibiotics is indicated.
Administration of acyclovir (a)is indicated in patients with presumed
meningoencephalitis caused by herpes virus. Antipyretic therapy (b)is
indicated for patient comfort, but repeat diagnostic evaluation is essential.
Sinus pain (c)can often present as a frontal, pulsating headache. Patients
may be febrile and can seed the CSF from direct extension of sinusitis. Nev-
ertheless, meningitis must still be ruled out and treated, even if there is CT
confirmation of sinus opacification. Analyzing CSF already in the labora-
tory (e)from a previous LP is not recommended.
336.The answer is a.(Tintinalli et al, pp 1375-1381.)Headaches caused
by a mass lesionare classically described as worse in the morning,asso-
ciated with nausea and vomiting,andworse with position.Rarely do
patients present with focal neurologic symptoms. When they do, imaging
is a necessary adjunct prior to leaving the ED. If a mass lesion is part of the
differential diagnosis, LP should be deferred until neuroimaging has been
performed because of the risk of herniation.
Cluster headaches (b)are rare, generally occur in males, last less than
2 hours,and present as unilateral eye or temporal pain. There is often unilat-
eral tearing, swelling, or nasal congestion. In contrast to the migraine patient,
patients with cluster headaches are typically restless. Cluster headaches respond
to ergots, triptans, and often high-flow oxygen. Tension-type (c)headaches are
bilateral, not pulsating, not worsened by exertion, and should not be associated
with nausea or vomiting. They generally respond to NSAIDs or acetaminophen.
Headaches associated with intracranial hypertension (d)are exacerbated by
changes in position (eg, squatting), are often frontotemporal, and may be asso-
ciated with disturbances of gait and incontinence. They are difficult to control.
Migraines(e)are generally unilateral, pulsating, associated with phonophobia
or photophobia, nausea, and vomiting. They are slow in onset and generally
last 4 to 72 hours. There is considerable heterogeneity in their presentation.
Most patients who are chronic migraineurs can describe their headache syn-
drome and are able to differentiate between their normal migraine and
another headache. Change in the character, intensity, location, or duration of
a migraine should prompt suspicion of another cause.