Cassandra Elliot: A 29-Year-Old Overweight Female With Constant Headache Pain That Worsens With Valsalva Maneuver

Learning Objectives

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Learn the common types of headache.
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Understand the difference between primary and secondary headaches associated with increased intracranial pressure.
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Develop an understanding of clinical presentation of specific headache types.
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Develop an understanding of the treatment of specific headache types.
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Develop an understanding of the differential diagnosis of headaches that increase with Valsalva maneuver.
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Learn the importance of fundoscopic examination in the diagnosis of headache.
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Learn how to identify factors that cause concern.

Cassandra Elliott

Cassandra Elliott is a 29-year-old intensive care unit nurse with the chief complaint of, “My head is killing me.” Cassandra stated that over the past 4 or 5 weeks, she began noticing that shortly after awakening, she began to experience a headache that involved her entire head. Cassandra stated that the pain was constant and throbbing in nature. I asked her if she noticed anything that made the pain worse and she said, “Lifting patients up in bed and straining at stool makes it feel like the top of my head was going to blow off. Doctor, I don’t mean to waste your time, but a few days ago a patient fell, and when I was helping lift him off the floor, my vision went out for a few minutes. I sat down and the sensation of looking through a tunnel gradually went away. I don’t mean to sound like a wimp, but I was really scared. I know that I need to lose some weight, and I thought I was having a stroke or something. The other thing that is really worrying me is that I am having trouble reading fine print. At first I thought I just needed to get some reading glasses, but I am scared that something really bad is going on.” I asked Cassandra if she had any numbness or other neurologic symptoms associated with her headache pain, and she just shook her head.

Cassandra denied any fever, chills, or other constitutional symptoms. I asked Cassandra if she had recently started any medications, specifically tetracycline, vitamin A, retinoids, danzol, or oral contraceptives, and she said no. I asked Cassandra what made her pain better, and she said that avoiding lifting or coughing seemed to help, but the use of acetaminophen and ibuprofen was of no value whatsoever. She denied significant sleep disturbance.

I asked Cassandra about any antecedent head trauma, and she just shook her head no. She volunteered, “Doctor, I am really scared. Do you think I have a brain tumor or an aneurysm or something? I’ve never had anything like this before. Something is definitely not right.”

I asked Cassandra to point with one finger to show me where it hurt the most. She held her temples and said that her entire head hurt. “Doctor, it really hurts all the time.”

On physical examination, Cassandra was afebrile. Her respirations were 18, and her pulse was 78 and regular. Her blood pressure was 130/78. Cassandra was overweight, with a body mass index (BMI) of 40. Cassandra’s fundoscopic examination revealed papilledema bilaterally ( Fig. 9.1 ). “Not good,” I thought. There were no cranial nerve abnormalities, and the remainder of her ear, nose, and throat (ENT) examination was unremarkable. Her visual acuity was grossly intact, but she appeared to have visual field defects. Her cardiopulmonary examination was normal. Her thyroid was normal. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. A careful neurologic examination revealed no evidence of peripheral neuropathy, entrapment neuropathy, or other abnormalities. Deep tendon reflexes were normal, and no pathologic reflexes were present.

Key Clinical Points—What’s Important and What’s Not

The History

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Recent onset of holocranial headaches in the absence of antecedent trauma
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Headache worsened with Valsalva maneuver
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Associated visual disturbance
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Patient is very concerned about her symptoms
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No history of fever or chills
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Patient specifically denies recently starting tetracycline, vitamin A, retinoids, danzol, or oral contraceptives

The Physical Examination

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Patient is afebrile
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Patient is female
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Patient is obese
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Bilateral papilledema present (see Fig. 9.1 )
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Visual field defects identified
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No cranial nerve palsies
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Neurologic examination is normal

Other Findings Of Note

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Normal ENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema

What Tests Would You Like to Order?

The following tests were ordered:

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Magnetic resonance (MRI) of the brain
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Visual field testing

Test Results

MRI of the brain revealed normal brain parenchyma with no evidence of hydrocephaly, masses, structural lesions, or meningeal enhancements, but some flattening of the posterior sclera and bulging of the optic discs were noted ( Figs. 9.2 and 9.3 ).

Visual field testing was markedly abnormal, with an abnormally enlarged blind spot and a nasal step defect affecting the inferior quadrants of the visual field ( Fig. 9.4 ).