Case 14: Headache and Unilateral Visual Changes

Presenter: Adam S. Fleisher, MDPreceptor: Justin McArthur, MBBS, MPH


July 18, 2002

In This Article

Case Presentation

A 49-year old right-handed woman presented to the Johns Hopkins Hospital Ophthalmology Emergency Center with worsening vision in her right eye. For the previous 2 months, she had noted mildly blurred vision in that eye, but it became worse over the last 2 days. She described it as a central opacification, "like a shadow," that expands at times. She complained of right eye pain on rightward gaze. She denies visual difficulty of the left eye or any diplopia.

She also complained of a waxing and waning headache over the last month that likewise worsened during the previous 2 days. She ranked the headache at 3 to 7 out of 10 in severity, and described a right hemicranial, constant aching with occasional throbbing, which worsened with activity and was not relieved by acetaminophen. The pain did not awaken her from sleep, but at times was associated with photophobia and phonophobia. She also complained of mild nausea, but no vomiting, and occasional visual phenomena she described as "flashing circles and squares on or below a line in her central vision."

She reported intermittent fevers as high as 103°F, a nonproductive cough, and mild neck soreness for the previous 3 weeks. In addition, she experienced a periodic tingling sensation in her hands and heaviness in her legs for approximately the same period of time. She described an occasional hot flushing sensation in her neck and head, and diarrhea for the last 3 days. She also complained of joint aches. She had not had contact with anyone who had similar symptoms. She denied experiencing either Lhermitte's or Uthoff's phenomena.

The patient was a social worker with a bachelor's degree in mental health. She had a 30 pack-year history of tobacco use, but no illicit drug or alcohol abuse.

The patient reported that many family members experience migraine headaches. Furthermore, her mother died after suffering subarachnoid hemorrhage caused by a ruptured cerebral aneurysm; her father had hypertension and a history of myocardial infarction; her maternal grandmother suffered deep vein thrombosis at age 40; and an aunt suffered a stroke at age 45.

The patient took acetaminophen occasionally, as well as over-the-counter cold remedies.


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