A 38-Year-Old Man With Double Vision, Numbness, and Headache

Olusegun John Oluwole, MBBS

Disclosures

July 28, 2020

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 38-year-old man presents to the emergency department with a moderately severe right-sided temporal headache that began the previous day while driving home from work. He tried regular over-the-counter pain medications, including acetaminophen and ibuprofen, with no improvement. He also tried to get extra sleep that night, but his symptoms did not improve.

He describes the headache as initially mild but gradually becoming moderate to severe within the first hour. At the time of presentation, he rates his headache intensity as 8 out of 10 on the visual analogue pain scale. It is throbbing in nature, worsens with movement, and is associated with light and sound sensitivity. In addition, he reports having double vision and seeing flashing bright lights in his visual field.

Upon further questioning, he describes some numbness and weakness in his right arm and leg. He believes it started several minutes before the onset of headache the previous evening. He admits having experienced a similar headache associated with weakness in his right-sided limbs 1 week prior, which completely resolved within 24 hours of onset. The episode that occurred 1 week ago was associated with nausea and vomiting, as well as transient loss of consciousness of several minutes at onset.

He does not remember having had any major headaches of this nature in the distant past. However, he reports having occasional bitemporal, throbbing headaches once or twice every 2-3 months over the past year. He has taken simple analgesics, such as acetaminophen, for those, with good response. He denies having any neck stiffness, facial weakness, swallowing difficulties, slurring of speech, sphincter disturbances, or seizures. He has no fever, upper respiratory symptoms, diarrhea, joint pain, or rash.

The patient has not traveled abroad in the past 6 months. He has had no contact with any known sick persons and has no significant past medical history. He does not consume alcohol or tobacco in any form and takes no psychoactive substances. He has no history of risky sexual behavior and no history of recent head trauma. He is the oldest of three siblings and recalls no history of headache disorder in his immediate family.

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