Case Challenge: Woman Presents to Emergency Department With Headache and Hypertension

Lisa M. Hollier, MD, MPH; Carolyn K. Holland, MD, Med; Brittany R. Behm, MPH; Eliza C. Miller, MD, MS; Jenna M. B. White, MD; Christopher M. Zahn, MD; Nicole D. Ford, PhD, MPH; Deborah Burch, DNP, RN; Bethany Scalise, BSN; Amy St. Pierre, MBA


September 23, 2022

Editorial Collaboration

Medscape &


A 25-year-old woman presents to the emergency department (ED) with report of a severe headache. The pain is constant, throbbing, and located in the occipital region of her head. Additional symptoms include occasional episodes of blurred vision.

Two days prior, she presented to an ED at a different hospital for severe headache. Her blood pressure was 152/98 mm Hg at admission and 156/106 mm Hg at discharge. Her lab results from that prior ED visit were reported to be normal other than a urinary tract infection, for which she was treated with antibiotics. She had a head CT that was reported to be negative and was given an IV medication that helped her headache. She was discharged with a prescription for butalbital-acetaminophen-caffeine. She reported that the prescribed medication initially helped with her headache but did not completely alleviate her symptoms, which prompted her visit to the ED today.

She has a history of headaches, but this one is reportedly much worse compared with her previous headaches. No surgical history is documented. She has no history of hypertension. She does not report fever, chills, neck pain or stiffness, chest pain, shortness of breath, vomiting, dizziness, seizures, syncope, weakness, lightheadedness, or recent trauma.

Physical Exam

On physical examination, the patient is a healthy-appearing woman, clutching her head with eyes tightly shut. Her blood pressure is 142/98 mm Hg, with a heart rate of 72 beats/min. Her respiratory rate is 18 breaths/min, with an oxygen saturation of 100% on room air. Her temperature is 36.8 °C (98.2 °F). Her weight 86.2 kg (190 lb) and height is 5'7" with a resulting BMI of 29.8.

The patient's general physical exam is normal. Her neck is supple with normal range of motion. She has no edema in her lower extremities. She has no bruising or lacerations. Her neurologic exam is completely intact (mental status, cranial nerves, motor, sensation, reflexes, and coordination).