Abstract Details

Title Recurrent Thunderclap Headaches as a Presenting Symptom of Coccidioidal Meningitis

Topic Headache

Presentation(s) P1 - Poster Session 1 (9:00 AM-5:00 PM)

Poster/Presentation
Number 206

Objective To report a unique case of coccidioidal meningitis presenting as recurrent thunderclap headaches.

Background Thunderclap headache refers to a headache that reaches its maximal intensity within seconds and is considered a “red flag” for secondary headaches. The differential diagnosis for thunderclap headache typically includes subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, vasculitis, and medication effects. There have been cases of certain vasoconstriction-causing infections resulting in this type of headaches, however not typically fungal infections.

Design/Methods A 58-year-old male with a history of asthma was referred to the headache clinic for recurrent thunderclap onset headaches for the past week.The headaches were described as sudden bilateral temporal and occipital pain, reaching maximum intensity of 9-10/10 within one minute of onset and associated with diagonal binocular diplopia. He denied positional component, neck pain, or infectious symptoms. He had no improvement with scopolamine patches, fioricet, rizatriptan, sumatriptan, rimegepant, or ibuprofen. On exam, he had right beating nystagmus with right gaze and gait imbalance without papilledema. MRI brain and MRA head and neck were unremarkable. Lumbar puncture showed an opening pressure of 23 cmH2O, nucleated cells 88, RBCs 2, glucose 30, protein 160.6, coccidioides IgM 4.2, IgG 10.3. He was treated with fluconazole 800mg daily with subsequent improvement of the headaches.

Results NA

Conclusions Coccidioidomycosis is a fungal infection caused by a soil-dwelling fungi, Coccidioides, and is endemic to the southwestern North America. The most common presenting symptom is a subacute to chronic headache with associated nausea and nuchal rigidity. Other symptoms can include altered mental status, fever, personality changes, and focal neurological deficits. Our literature review found no cases of coccidioidal meningitis presenting with thunderclap headache. This case highlights the importance of considering this diagnosis in patients with recurrent thunderclap headaches, especially in endemic areas.

Authors/Disclosures
Olivia Kingsford, DO PRESENTER	Dr. Kingsford has nothing to disclose.
Madeline L. Singer, MD	Dr. Singer has nothing to disclose.
Kerry L. Knievel, DO (Barrow Neurological Institute)	Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Abbvie . Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Biohaven . Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Lundbeck . Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Lilly. Dr. Knievel has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Pfizer. Dr. Knievel has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Lundbeck . Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for AbbVie . Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Amgen . Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Biohaven . Dr. Knievel has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Lundbeck . Dr. Knievel has received personal compensation in the range of $10,000-$49,999 for serving as an officer or member of the Board of Directors for Headache Cooperative of the Pacific . The institution of Dr. Knievel has received research support from Abbvie .

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