A 37-year-old woman presents to the emergency department
with a diffuse, sharp, pounding headache,
which started 2 hours earlier. She rates her discomfort as
4 on a scale of 1 to 10. Neck muscle soreness is also present,
but the pain does not radiate.
The patient has not experienced syncope; visual disturbance;
chest pain; light-headedness; dyspnea; difficulty
in walking, using her hands and feet, or swallowing; paresthesias;
altered mental status; slurred speech; vertigo; face,
ear, or jaw pain; nasal discharge; palpitations; diaphoresis;
abdominal pain; nausea; vomiting; or
diarrhea. She has not had any acute
She has hypertension for which
she erratically takes antihypertensive
medication, the name of which she
has forgotten. She has no personal or
family history of migraine or other
She does not smoke or use illicit
drugs; however, she drinks heavily 2
or 3 times a week. She is married and
lives with her family.
Temperature is 37C (98.6F);
pulse rate, 90 beats per minute; respiration
rate, 20 breaths per minute;
and blood pressure (BP), 190/110 mm Hg. The patient appears
to be in no acute distress.
Scalp and temporal arteries are not tender; pupils
are symmetric and reactive to light. Eye motions are normal,
and no cranial nerve deficits are apparent. Speech is
clear; gag reflex is intact. Tongue protrudes in the midline.
Fundoscopic examination shows the optic disc margins
are sharply defined; no hemorrhages are noted. Venous
pulsations are present.
No pronator drift or cerebellar dysfunction. Upper
and lower extremity reflexes are equal and symmetric. No
Babinski reflex; Romberg test is negative.