Endgames Picture Quiz

An unusual headache

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5602 (Published 16 September 2014) Cite this as: BMJ 2014;349:g5602
  1. Una M Graham, specialist trainee year 7, endocrinology and diabetes1,
  2. Mark Magorrian, consultant physician2,
  3. Paul Burns, consultant neuroradiologist3,
  4. John R Lindsay, consultant physician1
  1. 1Department of Diabetes and Endocrinology, Mater Hospital, Belfast BT14 6AB, UK
  2. 2Department of Stroke and Elderly Care Medicine, Mater Hospital, Belfast, UK
  3. 3Department of Neuroradiology, Royal Victoria Hospital, Belfast, UK
  1. Correspondence to: U Graham qublbc8{at}hotmail.com

A 68 year old woman presented to the emergency department with a 10 day history of gradual onset left temporal headache and scalp tenderness, which had increased in severity over this period. She had a 40 year history of migraine, for which she had been prescribed sumatriptan. She described her presenting headache as different from her usual migraine. She was otherwise well with no recent illness or head injury. On examination she was normotensive and her temperature was also normal. There was no evidence of meningism. Her temporal arteries were pulsatile and non-tender on palpation. She had no neurological deficit and no papilloedema on fundoscopy. Her left temporomandibular joint was tender.

Initial investigations showed normal inflammatory markers and an erythrocyte sedimentation rate (ESR) of 2 mm in the first hour. A computed tomogram of the brain was normal, with no evidence of haemorrhage. Lumbar puncture was performed with an opening pressure of 16.5 cm H2O (reference range 8-21). The results of cerebrospinal fluid analysis were normal. There was no evidence of haemorrhage on spectrophotometry—a sensitive method of detecting blood products in the cerebrospinal fluid.

Three days after admission she noted swelling of the tongue and difficulty in eating. She was able to swallow but found it difficult to move her tongue. She had no hoarseness. On examination her speech was dysarthric, and she had swelling over the left side of her tongue, with leftward deviation on tongue protrusion (fig 1). Taste and tongue sensation were normal. Careful examination of palatal movement identified no weakness.

Questions

  • 1. What is the differential diagnosis of headache in this patient?

  • 2. What is the neurological deficit described?

  • 3. How would you investigate this patient further?

  • 4. How would you manage this patient?

  • 5. What is the prognosis?

Answers

1. What is the differential diagnosis of headache in this patient?

Short answer

In this age group unilateral …

View Full Text

Sign in

Log in through your institution

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial

Subscribe