Stephen Knight MD FACEP
UAB Department of Emergency Medicine
Introduction
Headaches are a frequent complaint among Emergency Department patients. In most instances the cause is benign, symptoms can be managed in the Emergency Department, and the patient is often able to be discharged. As Emergency Physicians, we are also trained to consider the worst-case scenario, and in every patient to at least consider the possibility of more serious causes of headache, such as meningitis, subarachnoid hemorrhage, and intracranial hypertension. Below we will discuss an example of a more uncommon pathology, which also may be easily missed on our usual testing modalities.
Case Presentation
A 35-year-old male presented to the Emergency Department for acute headache. He has no past medical history, including no history of migraines or other headache syndromes, no personal or family history of connective tissue disorder or autoimmune disease. He and his family had just returned home 5 days prior to his presentation after vacationing at a destination theme park. The patient reported that while at the theme park he did ride a number of roller coasters, but does not remember any of them being particularly violent or traumatic. He denied any other trauma to the head or neck. He was feeling in usual state of health for the first 2 days after returning home, and then the next day began to develop upper back pain and worsening headache. The headache was gradual in onset but continued to worsen as time went by. It was noted to be strongly positional in nature, becoming much worse when he tried to sit up or stand. He ultimately decided to go to the ED after reaching the point where he was unable to stand due to the pain.
On his initial evaluation he was found to have a completely normal neurologic exam. He had no signs of menigismus, no C/T/L spine tenderness, and normal visual acuity. He had no systemic signs of infection. CT of the head and spine revealed no acute pathology.
The patient, however, remained in significant pain despite the best efforts of his treating physician. He was given “migraine cocktail”, in addition to multiple doses of IV hydromorphone, but had little to no relief of symptoms. His pain was well out of proportion to what would be expected in most benign headache syndromes. Considering this, MRI of the brain as well as the spine were then obtained in the ED. The MRI of the brain showed no acute findings; however, the MRI of the spine revealed an epidural fluid collection extending from C6 to S1. He was admitted to the hospital, CT myelogram was performed, which revealed the source of the leak to be a focal defect at the level of T12. Epidural blood patch was administered, and patient had subsequent relief in his symptoms.
Discussion
The differential diagnosis in a patient who presents with headaches after riding a roller coaster is wide ranging. This could include more benign etiologies such as migraine or post-concussive syndrome. Roller coasters have also been implicated in causing more serious pathology including vertebral artery dissection2, subdural hematoma3,4, and subarachnoid hemorrhage5. The case that we present today represents an additional consideration when evaluating someone for headaches in this context. On review of the available literature, we could find only one other example of a similar CSF leak, which was described in a case report in the Lancet in 19961. This can be a very difficult diagnosis to make, because as was illustrated in our case, the pathology was only seen on MRI of the spine. If the treating physician had obtained only CT imaging or even had gotten an MRI of the brain only, this might have been missed. A lumbar puncture was not performed in this example, however one would expect that this patient would have low opening pressure, which may help to clue the clinician to the cause. One thing that aided in the diagnosis of this patient was his severity of symptoms, which were refractory to most tools that we have in our toolbox for the treatment of headaches in the ED. The strongly positional nature of his headache also suggested intracranial hypotension as a causative factor. This patient additionally had noted some upper back pain which radiated throughout his chest. In retrospect, this was likely due to cord compression from the extra-dural fluid collection. This diagnosis, albeit rare, may be considered in a patient who doesn’t fit the picture of a benign headache.
Copyright permission has been obtained from the UAB Department of Emergency Medicine Division of Ultrasound, Dr. David C. Pigott MD, Co-Director of UAB EM Emergency Ultrasound.
References
- Schievink WI, Ebersold MJ, Atkinson JL. Roller-coaster headache due to spinal cerebrospinal fluid leak. Lancet. 1996 May 18;347(9012):1409. doi: 10.1016/s0140-6736(96)91048-x. PMID: 8637363.
- Biousse V, Chabriat H, Amarenco P, Bousser MG. Roller-coaster-induced vertebral artery dissection. Lancet. 1995 Sep 16;346(8977):767. doi: 10.1016/s0140-6736(95)91525-7. PMID: 7658882.
- Roldan-Valadez E, Facha MT, Martinez-Lopez M, Herrera-Mora P. Subdural hematoma in a teenager related to roller-coaster ride. Eur J Paediatr Neurol. 2006 Jul;10(4):194-6. doi: 10.1016/j.ejpn.2006.07.001. Epub 2006 Sep 1. PMID: 16949843.
- Williams KA Jr, Kouloumberis P, Engelhard HH. Subacute subdural hematoma in a 45-year-old woman with no significant past medical history after a roller coaster ride. Am J Emerg Med. 2009 May;27(4):517.e5-6. doi: 10.1016/j.ajem.2008.08.005. PMID: 19555640.
- Rutsch S, Niesen WD, Meckel S, Reinhard M. Roller coaster-associated subarachnoid hemorrhage–report of 2 cases. J Neurol Sci. 2012 Apr 15;315(1-2):164-6. doi: 10.1016/j.jns.2011.11.026. Epub 2011 Dec 15. PMID: 22177088.