Risk of an abnormal CT (not necessarily herniation) in meningitis increased by:.Cumulative evidence suggests if no history of immunosuppression, normal sensorium and no focal neurology – safe for LP without prior CT.If suspicious of space occupying lesion, must CT first.Papilloedema seen in raised ICP – need CT before LP (benign ICH or mass lesion).Eye – acute angle closure glaucoma, scleritis, endophthalmitis.ENT examination for sinusitis +- intracranial extension.May be cause of headache (PRES, RCVS, hypertensive emergency) or a sign of ICH.95% of meningitis patients present with at least 2/4 of classic triad + headache.Fever + neck stiffness + ALOC = classic triad of meningitis.Persistent of headache once temperature normalised suggests further evaluation for CNS infection.Pregnancy/post-partum, SLE, Behcet’s, vasculitis, sarcoidosis, cancer.Migraine in first-degree relative increases risk of migraine 2-4x.Personal or FHx of autosomal dominant polycystic kidney disease.Aneurysm or sudden death in first-degree relative (3-5x risk).Cocaine, amphetamines increases risk of ICH and reversible cerebral vasoconstriction syndrome.Prior headache history may obviate need for extensive workup.Chronic use of analgesics/anti-inflammatories may result in medication overuse headache/withdrawal/rebound headache.Medication – Anticoagulants, antiplatelets, recent antibiotics, chronic steroid use or immunosuppressants (eculizumab increases risk of meningococcal disease).
Fever – absence does not rule out infectious cause however (esp.Headache quality – change in severity, pattern, frequency, quality or intensity (workup as if first presentation).Onset with valsalva – intracranial abnormality.Onset during exertion – SAH or arterial dissection.10-14% of thunderclap headaches are from high-risk causesįeatures associated with high-risk causes.4% of presentations are due to high-risk causes.Inflammation: Involves dura at base of skull or nerves or soft tissues of head/neck.Traction: Stretching of intracranial structures due to mass effect.Tension: Contraction of muscles of head/neck.Pathological processes that lead to headache.Extracranial skin, mucosae, blood vessels, nerves, muscles, fascia.Structures in head capable of causing pain.Reversible cerebral vasoconstriction syndrome (RCVS).
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