Case 2: Severe Headache

23 year old female patient walked into the Emergency Department complaining of a severe headache. She had no history of headaches. The pain was 9/10 and she couldn’t localise it. She said she’d had a niggling headache since lunchtime time but it had worsened throughout the day. Described as a throbbing pain, which didn’t radiate down to her neck. At home she’d tried paracetamol which eased it very slightly to an 8/10. Not worsening on bending or coughing. She felt more comfortable with the light off and just wanted to go to sleep. No vomiting.

She stated her vision was fine at the time of review, but for about half an hour before the headache came on she reports not being able to see around the edge of both eyes. She denied any flashing lights or zig-zag lines, no speech disturbance and no weakness of her arms or legs.

She had no past medical history, had a contraceptive coil fitted but on no medications. She lived with her partner, worked in retail, non-smoker, no drugs, occasional alcohol binge.


BP 113/69, HR 77, Temp 36.7, RR 14, SpO2 99% on air

BMI 22

Visual acuity normal, all cranial nerves normal

No focal neurology

Fundoscopy no papilloedema

Differential Diagnosis

Diagnosis Rationale
Subarachnoid Haemorrhage Not sudden onset, no “thunderclap”

No focal neurology

Typical aura lasting less than 1 hour

No neck stiffness and some improvement of the headache with paracetamol.

Migraine Likely

Described aura


No other signs or symptoms

Right age group

Tension Headache Unusual for the headache to last more than a few hours

Unusual to have associated symptoms, i.e. visual disturbance

Cluster Headache More common in men

Usually unilateral

Usually sharp, stabbing pain around eye

Can have watery or red eye

Idiopathic Intracranial Hypertension Correct age group

No obesity

No papilloedema

Space Occupying Lesion Unlikely to present with headache especially as the only symptom

No signs of raised intracranial pressure

No focal neurology

Meningitis Systemically well

No neck stiffness, no vomiting, no fever, no rash

Giant Cell Arteritis More common in >50yrs age group

No scalp tenderness

Systemically well



Consideration for CT head


Paracetamol 1 g already had

NSAID – Aspirin 900mg

Anti-emetic – metoclopramide 10mg

Final Diagnosis

Migraine with aura

Useful Links

NICE guidance on headache

BASH guidance 

SIGN guidance on headache

Ottawa Subarachnoid rule