Headache at Onset of Acute Cerebral Ischemia

Abstract

CASE Ten days previously, this 76-year-old woman suddenly developed a shadow over the left field of vision of both eyes associated with a right temporal pressure headache with an intensity of 9/10. The headache resolved in 3 days. There were no other associated neurological symptoms. When seen in consultation, the right temporal headache had recurred the evening before for about 20 minutes with an intensity of 8/10 without associated symptoms. There was no prior history of headaches. There was a history of hypertension, type II diabetes, coronary artery disease post aortocoronary bypass, and cardiac arrhythmias requiring implantation of a permanent defibrillator-pacemaker. She was taking insulin, metoprolol, clonidine, and lasix. On examination, the blood pressure in the left arm while sitting was 210/110. Neurological examination was normal except for a left homonymous hemianopsia. A computerized tomography (CT) scan of the brain was consistent with a subacute infarction of the medial right occipital lobe. A carotid ultrasound study was normal.