292 Emergency Medicine
Migraine headaches (a)are recurrent headaches that may be unilateral
or bilateral. They occur with or without a prodrome. The aura of a migraine
may consist of neurologic symptoms, such as dizziness, tinnitus, scotomas,
photophobia, or visual scintillations. Persistent morning headaches and
personality changes in this case are inconsistent with the diagnosis of ten-
sion headache (b). Tension headache is described as bilateral pressure-like
pain, not worsened with activity and associated with stress. Headaches in
patients over 50 years of age are unusual and should be taken seriously and
well evaluated. Subarachnoid hemorrhage (c)typically presents with severe
headache of acute onset, classically described as “the worst headache of my
life,” with associated nausea and vomiting. Pseudotumor cerebri (d)or
benign intracranial hypertension is a disorder seen in young obese females
complaining of chronic headaches.
270.The answer is b.(Morris, 2006.)Eclampsia develops after the
20th week of gestation and is considered a complication of severe preeclamp-
sia. The progression from severe preeclampsia to seizures and coma is thought
to be a result of hypertensive encephalopathy, vasogenic edema-associated
cortical ischemia, edema, or hemorrhage. Therefore, a head CT should be
quickly obtained. Eclampsia is a clinical diagnosis with patients having
seizures without evidence of CNS, metabolic, or any other seizure etiology.
Most patients have systolic BP higher than 160 mm Hg or diastolic BP higher
than 110 mm Hg and proteinuria; however, eclampsia can occur with mini-
mally elevated BP—or elevated, relative to baseline—and without proteinuria.
Evidence of end-organ damage prior to development of seizures is common.
Symptoms include altered mental status, headache, visual disturbances,
and abdominal pain; signs include hemolysis, impaired liver function with
elevated liver enzyme levels, low platelets (HELLP), hemoconcentration,
proteinuria, oliguria, pulmonary edema, generalized peripheral edema,
microangiopathic hemolytic anemia, and fetal growth retardation. Eclampsia
is most common during the antepartum period, yet 20% to 25% of cases
occur during the postpartum period. Although postpartum eclampsia may
occur as long after birth as 3 weeks postpartum, most cases (98%) occur on
the first postpartum day. Eclampsia is not the cause of seizures that occur dur-
ing the first trimester or well into the postpartum period. These seizures are
suggestive of CNS pathology.
A complete blood count (a)and LP (c)are helpful if there is concern for
an infectious etiology of the seizure, such as meningitis. In addition, if you
are concerned for HELLP syndrome a complete blood count is necessary.