History and Present Illness

A patient in their mid-30s with a history of migraine presents to the emergency department (ED) with a posterior headache that came on suddenly 2 hours ago. The headache is associated with transient total body numbness and loss of coordination as well as a transient inability to swallow with drooling. The patient reports that the symptoms all started fairly abruptly after she sneezed violently about 3 to 4 times. The neurologic symptoms gradually resolved after about 15 to 20 seconds but the headache continues. She notes that this does feel like her typical headache but the other features she has never had before.

Vital Signs and Physical Examination

The patient’s vital signs are normal. Physical examination is also normal. A computed tomography (CT) of the head is ordered (Figure).

Figure. Cross-sectional and sagittal views of the brain stem of a patient with headache and neurologic symptoms. <I>Credit: Courtesy of Brady Pregerson, MD</I>

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Topics:

Clinical Challenge
Emergency Medicine
Headache
Neurology
Pain