Dados do Trabalho

Título

Headache secondary to meningitis due to M. tuberculosis responsive to nerve blockage: a case report

RESUMO

Case Presentation:
A 49-year-old male patient, with migraine since 10 years old, seeked medical attention with a new and distinct headache pattern that initiated in the previous two months and had a progressive intensity and frequency. It was described as a high intensity continuous pressure in the right frontal-parietal-occipital topography, with worsening periods of recurrent stabbing pain episodes. Initially, a cluster headache diagnosis was suspected due to possible autonomic features associated and a treatment with a right greater occipital nerve block, high-flow oxygen and sumatriptan when headache recurred was offered and preventive treatment with Verapamil was initiated. Also, laboratory and advanced neuroimaging investigation turned out negative. Two weeks later, he reported improvement in the right side pain but described a new headache with the same characteristics as before on the left side that didn’t respond to the prescribed treatment and reported a worsening of pain when lying down in his bed. A left greater and lesser occipital nerves block, trigger points injections in bilateral trapezius and left semispinalis were performed and a lumbar puncture was scheduled. Five days later, the patient had a marked headache improvement, presenting only 3 episodes in 2 weeks, with a mild intensity. Lumbar puncture revealed a mildly elevated opening pressure (270 mmH2O) with significant elevations in cell and protein counts. A PCR test for M. tuberculosis was positive and treatment for this condition was initiated.

Discussion:
A minority of headache patients have a secondary headache disorder and the medical literature promotes red flags to direct the clinician to initiate a workup plan. Sometimes, we may not proceed to further investigation even with a red flag present if the patient's headache presents significant improvement with medical treatment. In this case, our patient had significant response to bilateral occipital nerve blocks but, nevertheless, further investigation was warranted because of the presence of recent onset of new headache and positional headache.

Final Comments:
Neurologists worldwide estimate that 18% of patients with a headache have a secondary headache disorder. This case reinforces that even the improvement of headache with occipital nerve blockage or other treatments must not exempt the need to investigate the existence of a secondary cause of headache, which proved to be crucial for this patient.

Palavras Chave

Meningitis, M. tuberculosis, nerve blockage, red flag, headache