362 Emergency Medicine
a cerebral aneurysm but LP should be performed to confirm the presence
of intracranial bleeding prior to contrast-based imaging.
328.The answer is c.(Tintinalli et al, pp 1379-1381.) The headache
described is a menstrual migraine,a common variant of the migraine
headache syndrome.Appropriate abortive therapies (this headache is just
starting) are diverse and include IV ergot, triptans, and antiemetics. Suma-
triptan (Imitrex) is a triptan which acts by blocking the 5-hydroxytryptamine
(5-HT, serotonin) 1D receptor. It also has less associated nausea and vomiting
than ergots. It may have a higher incidence of minor side effects (flushing,
injection site reaction) and a higher relapse rate than ergots. Contraindications
to triptans or ergots include pregnancy, hypertension, coronary artery disease,
or use of either class of agent within the last 24 hours.
Opioid analgesics (a and e)are reserved for failed abortive therapy or
when there are contraindications to readily available abortive drugs. Opioids
decrease the pain associated with headache syndromes, but fail to interrupt
the neurochemical dysfunction. Frequent use of opioids for primary headache
syndromes is associated with poor outcomes. (b)NSAIDs and acetaminophen
are appropriate first-line therapy for patients with minor migraine symptoms.
If a patient has tried these in the past and they have been ineffective, there is
little utility in trying again. (d)Topiramate (Topamax) is an antiepileptic drug
that is used for migraine prevention in patients with frequent and difficult to
control headache syndromes.
329.The answer is a.(Goldman and Ausiello, pp 1693-1695.)In a case of
suspectedTA, initiation of corticosteroid therapy is indicated emer-
gentlyto prevent irreversible complications. Loss of visionis known to
occur and prompt initiation of corticosteroid therapy decreases this possi-
bility. TA, also referred to as giant cell arteritis, is a granulomatous inflam-
mation of the proximal great vessels and its carotid bifurcations. It has an
overlapping clinical syndrome with polymyalgia rheumatica.
The description of this headache syndrome is inconsistent with a SAH
(b), which classically presents with sudden onset of pain and is associated
with nausea, photophobia, and nuchal rigidity. It is rarely preceded by con-
stitutional symptoms. Injection of lidocaine at the base of the occiput is an
effective treatment for cervical neuralgia (c)but has no place in the treat-
ment or diagnosis of TA. (d)The patient’s clinical history is inconsistent with
meningitis. ESR (e)is normally elevated to the 50 to 100 range, but a mildly
elevated sedimentation rate does not rule out the diagnosis. Laboratory