A sudden headache

Abstract

A 55 year old woman attended the emergency department with a headache that had started suddenly at the back of her head 12 hours earlier. It had reached its peak intensity (10/10 in severity) within minutes and spread across her whole head. It was exacerbated by coughing, stooping forward, and movement of her head. She had no neck stiffness, photophobia, or limb or facial weakness. She experienced no sensory symptoms, and her vision was unaffected. On systems review, she last felt well two months before her current presentation. She had a persistently sore throat and a dry cough, despite completing her fourth course of antibiotics, during that time. The preceding day she had noticed swelling of the face, neck, and breasts, with some visible veins on the chest wall. She reported no wheeze, shortness of breath, or symptoms consistent with urticaria. She had no fever, rash, weight loss, or night sweats. She was a smoker of 40 pack years. Her history was non-contributory. Her family history showed her mother had died of metastatic lung cancer at the age of 66. She had no drug allergies. On examination, she was haemodynamically stable, saturating at 91% on room air, …