The Boy With The Headache

 

A 4 y.o. boy is brought to your office because of headaches. He first complained to his mother that his head hurt 2 weeks previously. He could not tell her when it started, but stated that the headache was continuous and seemed localized to the back of his head. He denied any aura, he was not nauseated and he had no visual obscurations.

 

The physical examination was normal except for blurred disk margins in both fundi and absent venous pulsations. On neurological examination, the boy walked with a wide-based gait and could not tandem walk. There was gaze-directed nystagmus on lateral gaze in either direction. His speech was slightly dysarthric. Rapid alternating movements of the tongue and palate were non-rhythmic. However he performed the finger-to-nose and heel-to-shin maneuvers well.

During the examination, the child complained of a headache.

Questions:

  1. What do you think is the anatomical localization of the abnormalities on the patient's examination?

  2. What test would you order to confirm you hypothesis about anatomical localization?

  3. What standard neurological procedure for headache diagnosis would you NOT perform in this patient?

  4. The test ordered above suggests a mass lesion. What is the differential diagnosis?
    What is your most likely diagnosis?
    What would be the differential diagnosis of the same lesion in an adult aged 45?

  5. What treatment would you recommend for your most likely diagnosis?
Last updated by Webmaster on August 18, 2009

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