56-Year-Old Woman With Positional Headache

Abstract

© 2011 Mayo Foundation for Medical Education and Research A 56-year-old woman presented to the emergency department with a 10-day history of sudden-onset, severe positional headache. She had awoken to sharp pain in the back of her neck extending into the occiput that subsequently radiated to the frontal areas bilaterally. She rated her pain as 10 on the 10-point severity scale. There was no history of recent head trauma. She had experienced associated nausea, vomiting, vertigo, increased pain when upright, and improvement when supine. Her medical history was remarkable for limited cutaneous scleroderma with CREST syndrome (named for its associated symptoms: calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia), type 2 diabetes mellitus, obstructive sleep apnea, hypercoagulable state with a positive lupus anticoagulant, hypertension with ischemic stroke, and multiple thromboses requiring long-term anticoagulation with warfarin. At presentation, all of her vital signs were within normal limits. Her physical examination was unremarkable, with the exception of hyperreflexia in the right upper extremity and bilateral lower extremities and left sixth cranial nerve palsy. Laboratory testing included a complete blood cell count, a metabolic panel, urinalysis, and measurement of troponin levels, which were all normal. The patient was noted to have a supratherapeutic prothrombin time with an international normalized ratio (INR) of 4.5 (target INR, 2.0-3.0).