Woman with Sudden Headache

Abstract

46-year-old lady had a long history of migraines for many years. Headaches were usually linked to menstrual cycle and usually well controlled by sumatriptan, diclofenac and propanolol (as preventative agent it reduced the frequency of headaches). She required diamorphine very rarely. She presented with a headache which she felt was “different” in nature. The previous night she was woken from sleep by the pain at around 3 am (this never occurred with her migraines) and took sumatriptan with minimal benefit or response. She described “feeling certain she was going to die” as her headache was very severe. She came to A&E with conclusion of left sided hemicranial and frontal pain. Objective examination was within normal limits with symmetrical reflexes, normal cranial nerves and no cerebellar signs. Only pathology found later was difference in pupil sizes. The left was smaller than right; sluggish but responding to light. She was hypertensive (156/106). Treating physician referred her for a non contrast CT brain which did not show any obvious pathology (no intracranial bleed). She eventually responded to opiates and her diagnosis was concluded as hemicrania/migraine. In following 48 hours her pain transformed into painful hypoesthesia of the scalp on the left (numb pain reported by patient). Asymmetry of pupils persisted. Patient was reviewed by neurologist 3 days later.