There are headaches and there are headaches ...

Abstract

Introduction: The frequency, diversity of aetiologies and clinical presentations of headaches makes of its diagnosis a challenge. This case illustrates the importance of a good anamnesis and clinical examination to achieve correct diagnosis, treatment and reduction of headaches morbidity and mortality. Case description: D.S.M.F, 47 years old white women, presented to her family doctor with malaise, photophobia, phonophobia, headache and vomiting. The examination revealed dolorous scalp and cervical muscle palpation. Total symptom remission was obtained with symptomatic medication. She came back on next day with previous symptoms worsening and visual abnormalities; space disorientation, incoherent speech, behavioural changes and superior executive functions impairment were observed. The patient was referred to the local hospital emergency service, where homonymous hemianopsia and papiledema were observed. Brain CT scan revealed signals of presumptive cerebral venous sinus thrombosis, confirmed by MRI. With treatment, first with heparin and afterwards changed to warfarin, progressive clinical improvement was obtained. Laboratory studies showed thrombocytopenia, hypercholesterolemia, hypertrigliceridemia and positive antinuclear antibodies. At the discharge from hospital, the patient maintained homonymous hemianopsia and was on warfarin. One month later, when she returned for follow-up, descriebed complaints of recent memory impairment and right homonymous inferior quadrantopsia. She received counselling about the disease, treatment, contraceptive use, diet and physical activity. Finally, a plan for periodic surveillance and subsequent study of trombofilia was established.