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Case Studies in Headache: When a Headache Is an Emergency

By Alan M. Rapoport, M.D.
Clinical Professor of Neurology,
The David Geffen School of Medicine at UCLA, Los Angeles, California, and founder and Director-Emeritus of the New England Center for Headache, Stamford, Connecticut

THE CASE
Lynda is a 44-year-old dental assistant who came to The New England Center for Headache in Stamford, Connecticut, with a one-week history of drooping of the right eyelid, a right-sided headache, and a diagnosis of cluster headache made by her family doctor. Her headache was intense and continuous, and her eyelid drooped more and more over the course of the week.

During my examination, Lynda told me she’d had a right-sided headache six months previously that was so severe she went to an emergency room for the first time in her life. All tests, including a spinal tap, CT, MRI and MRA (magnetic resonance angiogram, used to visualize the heart, blood vessels or blood flow in the circulatory system) were normal and the headache disappeared in about a week. At that time, she did not have a drooping eyelid.

The week before I saw her, however, she experienced the rapid onset of a right-sided, steady, intense pain which did not change. She gradually noticed that her eyelid was drooping. Everything was normal during my exam, except that her right eye was shut. When I lifted her eyelid and asked her to follow my light, the eye could only look to the right.

This finding concerned me. I did not think she had cluster headache, though that condition can be associated with a drooping eyelid, red and tearing eye, or stuffed or running nostril all on the same side as the pain. While these “clusters” of attacks are also quite severe, they last for only a short time (about 45-60 minutes) and reoccur a number of times per day, often at the same time every day, sometimes wakening the patient in the night. Lynda’s headache was constant.

DISCUSSION
A recent onset, intense, one-sided headache with neurological findings is always a red flag that suggests a more serious problem in the brain. Even though Lynda’s tests were normal, I decided to admit her to the hospital for an emergency angiogram. For this test, a catheter is placed in an artery in the groin and threaded up the arterial tree until it reaches the carotid artery in the neck. Then a dye is injected and x-rays are taken. This results in a better view of the blood vessels in the brain than with an MRA scan.

We discovered a small aneurysm pressing on the third cranial nerve at the base of her brain, which was causing her pain, drooping eyelid and paralysis of the right eye. The next morning, Lynda had an operation to clip the aneurysm. She came through the procedure well and her eye problems resolved over a six-week period.

Lynda did not fit the criteria for cluster headache and because her headache was recent in onset, severe and associated with neurological findings, she needed urgent evaluation, in spite of previous negative studies.

An aneurysm is a small out-pouching of a blood vessel with a thin wall. If an aneurysm ruptures, it causes a hemorrhage in the brain and the outlook is often dismal. If an aneurysm is discovered before it ruptures, and it is larger than 4-5 mm in diameter, it is often treated with either surgery or a coiling technique, whereby a small set of threads is introduced via a catheter to cause a firm coagulation that prevents future bleeding. If the aneurysm is smaller than 4 mm, it is usually observed.

While most headaches are not cause for alarm, if you have a new onset, one-sided, intense headache with neurological symptoms like numbness, weakness or eye symptoms, it may be a medical emergency and should be attended to immediately.

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