What caused a severe headache in a teenager?
A medical mystery looks at the cause of a severe headache, accompanied by stiff neck, nausea, vomiting, and high blood pressure.
The parents took their 15-year-old son to the emergency room after he awoke at 4 a.m. with a headache so severe, he declared it the worst of his life. He had a history of migraine headaches that had worsened over the past several weeks but this one was different. This headache involved both sides of his head and was unremitting. He also felt feverish and chilled and his neck felt stiff. The prior night, he had nausea and vomited. In the ER, the triage nurse noted that he was confused, had arm and leg swelling, and his blood pressure was very high (160/95, above the top normal adolescent reading of 120/80). She rushed him back to the treatment room for evaluation.
Our patient’s symptoms raised concerns for meningitis, a life-threatening inflammation of the membranes surrounding the brain and spinal cord. Classic symptoms of meningitis are headache, fever, nausea, vomiting, and stiff neck. It is usually caused by a virus or bacteria.
Although our patient felt feverish, his temperature was normal. The medical provider flexed the boy’s neck forward and there was no resistance. In addition, his white blood cell count was normal and tests for the usual viruses and bacteria that can cause meningitis were negative, making infection unlikely. Also, review of his immunization records revealed that he had received the recommended meningitis vaccination. Phew, not meningitis.
Although previously a good student, the teen told us he was flunking 9th-grade geometry and history. Poor school performance, confusion, and high blood pressure raised concerns for substance abuse. But he told us he wasn’t using, and his urine drug screen was negative.
Concerned about his recent increase in migraines, his parents took him to a neurologist two days before the ER visit. The neurologist prescribed Depakote to prevent his migraines, and the teen took his first dose the prior evening. Though side-effects of Depakote include headache, confusion, and swelling of the extremities, he vomited up the pill, so we could eliminate that possibility too.
Solution
The keys to our patient’s diagnosis were in his blood tests and something he later revealed. His blood chemistries showed an elevated blood urea nitrogen (BUN) and creatinine indicating acute kidney injury. Symptoms and signs of AKI include high blood pressure, swelling, confusion, fatigue, and decreased urine output. Healthy kidneys make urine that control the body’s water and eliminate waste.
Causes of AKI include infections, substance abuse, and medication use and misuse. On further questioning, our patient disclosed that for the past three weeks he had been taking frequent and extra high doses of ibuprofen (brand names Advil or Motrin), a nonsteroidal inflammatory drug, due to his worsening headaches. He was taking 800 mg of ibuprofen every four hours! The appropriate dose for his age is at most 600 mg every 6 hours. Diagnosis: AKI from overusing NSAIDs.
Our advice
Ibuprofen is an over-the-counter NSAID that can be used to decrease pain and fever and is generally safe for children older than 6 months old when used at the proper dose and interval.
Ibuprofen can be given every 6-8 hours and no more than 4 doses should be given in a 24-hour period. Children’s doses depend on their age and weight, and the concentration of the medication if liquid; please check the label or ask your child’s medical provider if you are not sure of the safe dose.
Make sure that your child is not taking multiple medications that contain NSAIDS as they can be found in many cold, allergy, and pain medications.
Parents, please monitor your children’s use of over-the-counter medications.
Examples of other names of NSAIDs include Motrin and Advil (Ibuprofen), Aleve (Naproxen), and aspirin.
Alexandra Vincent is a pediatric resident and Rima Himelstein is an adolescent medicine specialist at Nemours Children’s Hospital, Delaware.