326.A 27-year-old woman with known idiopathic intracranial hyperten-
sion (IIH) presents to the ED complaining of a bifrontotemporal headache
several times a day for 6 weeks after running out of her medications. She
complains of occasional pulsatile tinnitus but no visual disturbances. Fun-
duscopic examination reveals no papilledema and normal venous pulsations.
Which of the following factors determines the need for urgent treatment in
patients with IIH?
a. The presence of papilledema on funduscopic examination
b. A history of pulsatile tinnitus
c. Presence of an empty sella on CT scan
d. Complaint of visual loss or visual disturbances
e. A history of concomitant minocycline use
327.A 57-year-old man with a past medical history of hypertension and
migraines presents to the ED complaining of a headache that started 2 days
ago. He states the headache began suddenly with peak intensity while he was
defecating. The pain is continuous particularly in the occipital region and is
associated with mild nuchal rigidity and mild photophobia. He denies hav-
ing a recent fever. A noncontrast head CT is obtained and is normal. Which
of the following is the most appropriate next step in management?
a. Administer metoclopramide for nausea relief and ketorolac for pain control
b. LP
c. Empiric treatment for meningitis with IV antibiotics
d. IV mannitol to lower intracranial pressure (ICP)
e. Angiography to evaluate for an aneurysm
328.A 27-year-old woman presents to the ED complaining of headache
lasting approximately 1 hour in duration that is unrelieved by aspirin and
acetaminophen. She states the headache was not preceded by any visual
phenomena, is left sided, pulsatile, and has occurred nearly monthly coin-
ciding with her menstrual period for the past 6 months. She also complains
of nausea and sensitivity to sound and light. Which of the following is the
most appropriate therapy for this patient at the time of presentation?
a. IV morphine sulfate
b. Another trial of aspirin and acetaminophen
c. Sumatriptan
d. Topiramate
e. Hydromorphone and acetaminophen
348 Emergency Medicine