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A persistent headache

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2966 (Published 16 June 2010) Cite this as: BMJ 2010;340:c2966
  1. A J Dawson, clinical research fellow1,
  2. C Rowland-Hill, consultant radiologist2,
  3. S L Atkin, professor of diabetes, endocrinology, and metabolism1
  1. 1Department of Diabetes, Endocrinology and Metabolism, Michael White Diabetes Centre, Hull HU3 2RW
  2. 2Department of Radiology, Hull and East Yorkshire NHS Trust, Hull HU3 2RW
  1. Correspondence to: S L Atkin stephen.atkin{at}hyms.ac.uk

    A 34 year old man was admitted to the medical admissions unit with a history of headache and vomiting. He had been experiencing neck pain for the preceding four months; his headache had developed gradually over this time but had worsened over the past two weeks. The headache was described as a “throbbing” sensation over the frontal area of the skull radiating to the neck, and the patient felt as if his scalp “was being ripped on and off.” The headache was not related to the time of day. He also described some pain over his left eye. He had a two week history of vomiting associated with the headache, but no photophobia. On further questioning, he had not noticed any change in his libido.

    On examination the patient did not have a fever (temperature 36.8°C) and was haemodynamically stable (respiratory rate 15 breaths a minute, heart rate 85 beats a minute, blood pressure 125/65 mm Hg). Clinical examination of the neurological system determined papilloedema, and visual fields were noted to show a bitemporal hemianopia. Endocrine examination revealed reduced body hair; testes were not examined. All other system examinations were unremarkable.

    Blood tests initially showed a haemoglobin concentration of 155 g/l, a white cell count of 12.0×109/l (neutrophils 10.1×109/l), a platelet count of 225×109/l, a urea concentration of 5.3 mmol/l, and a serum sodium concentration of 136 mmol/l, potassium concentration of 3.7 mmol/l, and bicarbonate concentration of 27 mmol/l.

    Computed tomography of the head was performed, followed by magnetic resonance imaging (fig 1).

    A subsequent blood test showed a prolactin level of greater than 1 035 190 pmol/l (reference range 207-725), an 8 am cortisol concentration of 75 nmol/l, a thyroid stimulating hormone concentration of 0.6 mIU/l (0.5-4.7), a free thyroxine level of 11 …

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