Case presentation

A 57-year-old British Sri Lankan woman had a 10-week history of intermittent right-sided posterior headache and persistent fatigue. The headache had started behind the ear when on holiday in Sri Lanka and had migrated to the back of the head. There was an associated bilateral pressure-like sensation, worse in the morning and when bending forward. It occurred 3–4 times a day, lasting 10–15 min. She took paracetamol daily. There were no visual symptoms, scalp tenderness, jaw claudication, nausea, vomiting, photophobia or phonophobia. Medical comorbidities included alpha thalassaemia trait and prediabetes.

On examination, she was afebrile, alert and orientated. Neurological examination including funduscopy was normal. Her temporal arteries were non-tender on palpation. Recent blood tests were normal except that the erythrocyte sedimentation rate (ESR) was 63 mm/hour (<30) and serum C reactive protein (CRP) 23 mg/L (<10).

She had visited a doctor in Sri Lanka for the headache and had completed a course of oral antibiotics for a presumed ear infection, but her symptoms had persisted after returning home. She had visited her general practitioner and the emergency department and had received one dose of prednisolone 50 mg for possible giant cell arteritis.

What is your differential diagnosis and what would you like to do next?

Although she appeared well, there were multiple red flags to suspect secondary causes of headache, such as a space-occupying lesion.1 These include a new headache in someone aged over 50, unexplained raised ESR and CRP, positional headache, progressive symptoms (development over 10 weeks) and atypical presentation for migraine or other primary headaches. Frontal lesions can present with symptoms of raised intracranial pressure before causing focal deficits, and neurological examination initially may be normal.

We arranged a CT scan of the head with contrast (figure 1).