59 Year Old Female: Intermittent Head Pain

One of my co-workers told me that she wants to see more case studies.

A 59-year-old female presents to the emergency department with a chief complaint of “head pain that comes and goes.”

She describes the pain as a dull ache in her occiput that’s been striking without warning a couple of times per day for the past ten days. Over the last three days she’s noted that it has also been radiating into her neck and upper back/shoulders.

Onset – 10 days prior
Provocation/Palliation – None that she can identify
Quality – Dull ache that gradually worsens over the first few minutes
Radiation – Sometimes to her neck and upper back/shoulders
Severity – Around 9 out of 10 at its worst
Timing – Intermittent, each episode lasting ~10–15 minutes

Signs/Symptoms – A well-appearing 59yo F in no acute distress; symptoms as described above. She denies any associated nausea/vomiting/shortness-of-breath/lightheadedness/palpitations/syncope, but has occasionally experienced blurred-vision.
Allergies – No known drug allergies
Medications – Metformin, sitagliptin, insulin glargine, lisinopril
Past Medical History – Type II diabetes mellitus, hypertension, occasional migraines, appendectomy (40 years prior)
Last Oral Intake – Dinner three hours prior to arrival
Events Preceding Presentation – She experienced another spell at dinner and it self-resolved, but then a few hours later it came back and disappeared again. Realizing the episodes were becoming more frequent, she decided to get checked-out and drove to the ED. While she is signing in at triage she mentions that the pain is starting to come back.

Temperature – 36.9 C (98.4 F)
Heart Rate – 80 bpm
Blood Pressure – 142/88 mmHg (NIBP)
Respiratory Rate – 15 /min
SpO2 – 97% (room air)

Because of her vague symptoms and pain that involves her back/shoulders, a 12-lead ECG is performed soon after arrival.

1169 - 01a

What do you see?

What are your next steps in workup/management?

***The conclusion to the case is now posted!***


  • victor says:

    ritmo sinusal con hemibloqueo anterior izquierdo eje < -30º ,infradesnivelacion 1 mm I,AVL V1,V2

  • abdelmuti alsyouri says:

    Difficult case if only to diagnose from history and the ecg,that is showing sr,lad,subtle changes in Avl,lead 1,and v1to v3,
    cervical spine x-ray,doppler of the carotids,fundal exam.
    and then to procede accordingy to findings.
    to give NSAID.

  • Joe says:

    In my ed: cancel the ekg, CT head, IM toradol and discharge home.

  • John says:

    Down sloping st in AVL. STE in lead 3. Starting of inferior MI.


    This appears to be a case of vertebral artery stenosis or spasm that may present as headache with features of radiation
    As next plan in emergency we should post this patient for MR angiography of brain.

  • Supermedic! says:

    This could be some sort of angina. Give a nitro see what happens. There is some suspicious stuff. Reminds me of a 12 lead class I took with a pt who had a STEMI, then got a nitro and no STEMI – the theory being that the nitro dilated the arteries enough.

  • Floyd Miracle says:

    Can pain be controlled with nitro? Emergent echo and/or trip to cath lab. LVH is present, and if the elevation in the Inferior leads were our only finding, this would be an extremely difficult ECG IMO. However, there is some subtle ST depression in the anterior leads, so when “considering the company it keeps”, this is almost certainly a STEMI.

  • Liam says:

    Looks to be a future IMI forming given the EKG, but could be an ACS issue. Need to do serial EKGs and labs.

  • jotham gikuhi says:

    consinder inferior MI , lead iii, AVF ST elevation , but not on lead ii? the chances of having Inferior MI increases with reciprocal changes in AVL which is present , consider posterior wall involvement V2 ST depression. so if cardiac markers are relevant consider , cardiac cath soon . if not do echo , CBC,CMP,
    if results above report ambiguous, consider vascular spasm .
    hold on to managing pain unless debilitating this might lead us to more clue .

  • Eric says:

    Just from the EKG, get a posterior set due to st depression in precordial leads. Concerning pattern for circumflex stenosis.
    Older female, diabetic just screams abnormal presentation.
    Nuero exam, HEENT exam, blood sugar?

    Thanks, always enjoy the site and posts.

  • Ron says:

    I would have to go along with the inferior MI in the making. Would do the V4R to check for posterior involvement while treating with a modified ACS format to not make the condition worse.

  • Paul says:

    I’m all for an echo and CT MRA head and neck in addition to other minimally invasive strategies mentioned, but I would not be rushing this patient to a cath lab (not yet, anyway). I don’t feel there is enough evidence to justify it at the present time. My index of suspicion for an evolving MI is moderately high, but I would at least like to see some labs and imaging before committing a patient to an invasive approach that I’m not completely convinced they need.

  • Karen says:

    I agree with Paul. As long as she’s stable I wouldn’t rush her to cath. I would, however be comparing her EKG to older ones and waiting to see what her cardiac enzymes show.

  • Brent says:

    I dont know where you guys are seeing this STEMI in either of the leads. If anything i see an abnormality in the T wave and slight depression in Leads V4 and V5

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