Clinical Reasoning: A 23-year-old woman with fever and vertical diplopia.

Abstract

A 23-year-old woman with a history of uncomplicated migraine headaches presented with 2 days of headache. Her typical migraines were preceded by visual aura and usually resolved after taking a triptan. This headache was different in that there was no preceding aura, it did not respond to Imitrex, and it was accompanied by nausea/vomiting, dizziness, subjective fevers, and binocular vertical diplopia. She had had a mild upper respiratory tract infection 1 week prior to presentation. She had no sick contacts or recent travel history. Initial bedside examination showed hypertropia OD (figure 1) that did not change with direction of gaze. The degree of hypertropia improved with supine positioning. Her extraocular movements were otherwise not restricted, and her pupillary responses were normal. She had no other abnormalities on her neurologic examination.