Stephanie Ellison: A 32-Year-Old Graphic Designer With Severe Throbbing Left-Sided Headaches

Stephanie Ellison

Stephanie Ellison is a 24-year-old graphic designer with the chief complaint of, “My head is throbbing and I’m going to throw up.” Stephanie stated that she has had several headaches a month her entire adult life, but over the past several weeks, she has been having debilitating headaches that are getting worse. She said that the headaches have been so bad that she was way behind on her work and that her boyfriend had just about quit speaking to her. I asked Stephanie if she had ever had anything like this before and she said, “I’ve had headaches since I started my periods, but they seem to have gotten worse since I started working from home. So, I don’t know what to do! Nothing makes these headaches better. I know when I am going to get one, but Doctor, once they start, I am just sicker than a dog. All I can do is grab a pan to throw up in and go hide in a dark room.” To prove her point, she grabbed the wastebasket next to the examination table and had the dry heaves right there. By the time she finished, tears were running down her face and she closed her eyes and sobbed.

I tried to help Stephanie calm down, and after she tried to vomit a couple more times, I asked her if she had identified anything that triggered her headache and she immediately answered, “My periods.” She continued, “I also sometimes get them when my sleep is messed up or when I have the stress of a deadline.” I asked her if she was ever woken up with a headache, and she said no, but they often occurred in the morning. “They also got worse when my gynecologist changed my birth control pills because my insurance changed.” I asked if anyone else in her family had similar headaches and she said that both her mom and her aunt had the same headaches, but they got better with menopause. I asked if she knew that she was going to get a headache before it actually started and she said, “Absolutely. It’s the craziest thing. When I am going to have a headache, it feels like everything looks like it is in a high-definition movie with the subwoofers turned all the way up. I then start to get really sensitive to the light of my computer screen, everything is too loud, and any strong odors make me want to gag. The other crazy thing is that I can’t stop yawning. It drives my boyfriend crazy. I just keep yawning over and over again even though I am not tired. Then my vision in my left eye gets all jiggly and shimmery and glittery and I know I am really in trouble. I still don’t have any headache, but I know that there is no going back. I’ve tried all of the usual over-the-counter medications like Excedrin Migraine and those Imitrex shots, but once the eye thing gets going, nothing works to stop the headache.” I asked if she had any weakness associated with her headache and she said, “No, just the eye thing, and the nausea and vomiting. I’ve gotten so dehydrated from the vomiting that I have ended up in the ER a bunch of times. I heard one of the nurses tell the ER doctor that I was a frequent flyer…as if I had a choice!” She started crying again. I asked if she experienced smells that nobody else could smell or if she had any difficulty finding words or speaking, and she again said no. “Look, Doctor, I’m not making this stuff up.” I told her that I believed her and thought that I had a pretty good idea what was going on.

I asked her what made it better and she said that really nothing worked once the headache got going. Sometimes the shot of demerol and phenergan they gave her in the ER let her go home and sleep the headache off. She started crying and said, “Doctor, what am I going to do? Do you think I have a brain tumor? That’s what my boyfriend says!”

I asked Stephanie to use one finger to point at the spot where it hurt the most. She pointed to her left temple. I asked her what the pain was like—an ache, sharp, stabbing, burning—and she immediately said, “throbbing.” I asked whether the headache was on both sides or just one side, and she immediately answered, “It’s always on my left side.” I asked Stephanie from the time that she knew that she was going to get the headache until the time it was at its worst, was it a period of seconds, minutes, or hours, and she said, “It is always at least a couple of hours before it’s the worst.”

I asked Stephanie if I could examine her and she said, “You can pull out a couple of toenails if you can get rid of my headaches.” I smiled and said that I hoped that would not be necessary. On physical examination, Stephanie was afebrile. Her respirations were 16 and her pulse was 84 and regular. Her blood pressure was 126/80. There were no cranial abnormalities, and her ears and throat were normal. When I grabbed my ophthalmoscope to examine Stephanie’s eyes, she asked in a weak voice, “Do you have to shine that light in my eyes? I am really sensitive to light with my headaches.” I told her I would be as quick as I could, but that I really need to check things out. Her pupils were round, equal, and reactive to light. It took a little effort to perform a fundoscopic examination because Stephanie kept pulling away from the light. I reassured her and was happy to note that there was no papilledema. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, but she was a little tender to palpation from all the vomiting. No rebound tenderness was present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. Stephanie’s mental status exam was within normal limits.

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