Cases for finals #10 – history

28 year old woman

  • recent D&V
  • 4 days of increasing headache; now 8/10; generalised
  • vomiting worse
  • vision feels blurred; can’t read her book


First thing to decide is if you think this is a primary or a secondary headache.

Primary means migraine, usually, and whilst it can make you vomit, and can last days, doesn’t tend to crescendo. It can also cause visual distrubance but this is transient.

Alternatively, do you think this is secondary? This could mean anything – vascular, neoplasm, infection, inflammation etc. etc.

If this is your concern then you are looking for:

  • abnormal signs – visual function, optic nerve appearances, focal neurology, meningism
  • abnormal tests – elevated inflammatory markers, fever, abnormal scans

Lastly, it is unlikely to be a primary headache as I’m posting it here – so your real question is what is top of your differential and why.

Note – this is a real case that was missed on the acute take and picked up a week later. See if you can do better!


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  1. Hi Neil, that’s really interesting! I once heard of a case, a young lady presented with subacute headache, very similar symptoms to this one. And it was hydrocephalus secondary to aqueductal stenosis at the end. Some doctors tell me it may link to birth control pills, I wonder if that’s real risk factor? Thanks 🙂

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