A 42-year-old woman with a history of chronic migraine headaches presents to the emergency department (ED) for evaluation of a headache. She states that this headache is different than the migraines she typically experiences. The pain onset is more rapid with vomiting occurring earlier in the headache course than is usual for her. The location of the pain is also atypical for her: it is both frontal and occipital as opposed to being primarily frontal. She has no difficulty with speech, swallowing, or ambulation; she has no fever, abdominal pain, or other complaints.

Her vital signs are normal except for a pulse of 95 beats per minute and blood pressure (BP) of 147/91 mm Hg. The only physical examination finding of note is mild photophobia. Initial diagnostic tests include a complete blood count and basic metabolic panel; findings from these tests are within normal ranges. A computed tomography (CT) scan of the patient’s head is also taken.

Can you diagnose this condition? What is the next best step in testing and treatment?

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