A 44-Year-Old With a Headache, Photophobia, and Phonophobia

James Lee, MD; Stephanie Oh, PhD; Gaurav Gupta, MD

Disclosures

November 13, 2019

Editor's Note:

The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 44-year-old, right-handed woman presents to an outpatient clinic 1 month after being diagnosed with influenza, for which she received treatment with oseltamivir. She reports that 2 weeks after her illness, she began experiencing an insidious headache along her left occipital region. She also describes left ear hyperacusis, difficulty furrowing her left eyebrow and closing her left eye, left-sided tongue numbness, and left facial asymmetry. At that time, she presented to her primary care physician, who indicated that it was probably due to the effects of her viral illness. She prescribed the patient prednisone and valganciclovir for 1 week, with no improvement in her symptoms. She was also given an eye patch and eye drops, as well as a prescription for physical therapy.

The patient reports having photophobia, phonophobia, and lightheadedness associated with her symptoms. She reports using ibuprofen, with moderate improvement in the aforementioned headache. She denies any history of similar headaches. The patient otherwise also denies any history of recent travel, hiking, or tick exposure, as well as any fevers, rashes, or joint pain.

Her medical history is significant for irregular menstrual periods, for which she is on oral estrogen-based contraception. She also has a history of Raynaud syndrome-associated bilateral leg pain, for which she was successfully treated with verapamil and pregabalin, with resolution of her symptoms.

She describes no significant surgical history. In terms of her family, she is a married, heterosexual woman with two healthy children. Her parents are both alive, in their 70s, with a history of hyperlipidemia. She denies any known family history of cancer, thyroid issues, or autoimmune disease.

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