A pain in the neck type of headache

A 29 year old right hand dominant chef presented to the emergency department with a four day history of feeling “not normal.” He was sent home from work because of a gradual onset of dull pain on the left side of his neck radiating up into his head, which was getting progressively worse, as well as “seeing two of everything.” The pain was not influenced by changes in posture. In addition, his right side felt numb and he was dropping things at work. He felt unsteady on his feet, which prompted him to seek medical advice. He thought all his symptoms had come on suddenly and were gradually getting worse. He denied any recent alcohol consumption, illicit drug use, seizure activity, head injury, or loss of consciousness. He had no medical history of note, apart from hypothyroidism, for which he was taking thyroxine.

On examination, he was alert and orientated. His blood pressure was 141/94 mm Hg and other vital signs were normal. He had moderate weakness on the right side (Medical Research Council grade 4), mainly in the upper limb, with pronator drift, and reduced sensation to pinprick, light touch, and proprioception on the same side. There was evidence of a resting and intention tremor, with dysdiadochokinesia of the upper limbs, which was more evident on the right side than the left. Furthermore, he had a broad based gait consistent with cerebellar ataxia when attempting to walk. He had an upgoing plantar response on the right and a downgoing one on the left. His pupils were equal and reactive to light, but he had diplopia on both extremes of gaze, although there was no clinical evidence of ocular palsy. Papilloedema was not detected on examination of his fundi.

Given his history and the constellation of findings on examination, a …