Clinical Analysis: Sudden Right Arm Stiffness + Right Face Numbness

Localization First

"Marked motor and sensory disturbances are the hallmarks of occlusion of the MCA... usually are more pronounced in the arm and face than the leg. Such disturbances may involve only part of an extremity or the face but almost always are accompanied by numbness in the same region."

• Rosen's Emergency Medicine

Top Differential Diagnoses

Localization Details

• Pure Sensory Stroke - lacunar infarct at the ventroposterolateral (VPL) nucleus of thalamus
• Pattern: cheiro-oral (hand + face) distribution is classic
• "PSS is characterized by numbness, paresthesias, and a hemisensory deficit involving the face, arm... Sensory manifestations are primarily distal with a cheiro-oral... pattern." - Localization in Clinical Neurology

• Left MCA occlusion (cortical branches) or
• Sensorimotor stroke (posterior limb of internal capsule)

Emergency Assessment: Act NOW

1. B - Balance: Check gait
2. E - Eyes: Visual field defect?
3. F - Face: Facial droop?
4. A - Arm: Arm drift/weakness?
5. S - Speech: Aphasia, dysarthria? (dominant hemisphere involvement = LEFT hemisphere = aphasia likely)
6. T - Time: Record exact onset time immediately (critical for thrombolysis eligibility)

• Gaze preference toward the left (affected hemisphere)
• Aphasia or language difficulty (left hemisphere dominant in most people)
• Hemianopsia (visual field cut)

Immediate Investigations

Risk Factors to Assess

• Hypertension (systolic ≥140 or diastolic ≥90 mmHg) - most common
• Atrial fibrillation (cardioembolic)
• Diabetes mellitus
• Dyslipidemia
• Smoking
• Family history
• Prior TIA (risk of stroke at 2 days = 10%; at 90 days = 15%)

Management Principles

• IV tPA (alteplase) within 4.5 hours of symptom onset (strict exclusion criteria apply)
• Mechanical thrombectomy for large vessel occlusion - up to 24 hours in selected patients
• Antiplatelet therapy (aspirin 300 mg loading dose if no hemorrhage)
• Admit to stroke unit / ICU
• Maintain BP, glucose, temperature
• Early physiotherapy, speech therapy

• Same workup as stroke
• Start aspirin + statin immediately
• ABCD2 score to risk-stratify
• Dual antiplatelet (aspirin + clopidogrel) for 21 days in high-risk TIA per current guidelines
• Address modifiable risk factors urgently

Bottom Line

• Rosen's Emergency Medicine, p. 1427
• Localization in Clinical Neurology 8e, p. 1380-1381
• Frameworks for Internal Medicine, p. 574

Loss of Sensation in Right Arm - 27-Year-Old Male

Why Age Matters Here

• Peripheral nerve / entrapment
• Cervical radiculopathy (disc herniation - common even in young adults)
• Brachial plexus injury
• Demyelinating disease (Multiple Sclerosis - peak onset 20-40 years)
• Thoracic outlet syndrome
• Functional / psychogenic

Step 1: Localize the Lesion

A. Peripheral Nerve Pattern (Confined to one nerve territory)

B. Cervical Radiculopathy Pattern (Root territory)

• Localization in Clinical Neurology 8e, p. 228

C. Brachial Plexus

• If the entire arm (all nerve territories) is numb with absent reflexes and motor loss = brachial plexus (C5-T1)
• Causes in a young man: trauma (contact sports, fall, motorcycle accident), thoracic outlet syndrome, heavy backpack (rucksack palsy), or Parsonage-Turner syndrome (neuralgic amyotrophy - acute onset severe shoulder pain followed by weakness/numbness)
• "No single peripheral nerve lesion could produce paralysis and sensory loss in the entire arm ending sharply at the shoulder" - Neuroanatomy through Clinical Cases 3e

D. Cervical Spinal Cord / Myelopathy

• Numbness of arm + any leg symptoms, balance problems, Lhermitte's sign (electric shock down spine on neck flexion) = spinal cord involvement
• Look for upper motor neuron signs: hyperreflexia, Babinski sign, spasticity (these distinguish central from peripheral)
• Tintinalli's: "Lateralization of weakness, hyperreflexia, positive Babinski's sign, or any other CNS finding requires further investigation for a central rather than peripheral disorder"

E. Multiple Sclerosis (MS) - Must Not Miss

• Peak onset: 20-40 years, male:female ~1:2, but absolutely occurs in men
• Sensory symptoms (numbness, tingling, heaviness of a limb) are the most common FIRST symptom of MS
• Often described as "wearing a glove" or "dead arm" sensation
• Lhermitte's sign strongly suggests demyelination
• Other features: optic neuritis (painful vision loss), fatigue, bladder dysfunction, previous episodes that resolved (relapsing-remitting pattern)
• MRI brain + spine with gadolinium is the key investigation

Key Distinguishing Questions to Ask

1. Onset: Sudden (vascular, MS, trauma) vs. gradual (entrapment, spondylosis)?
2. Location: Exactly which part of arm - hand only, forearm, whole arm?
3. Character: Numbness only, tingling, burning, "dead" feeling?
4. Neck pain/radiation: Radiating from neck = radiculopathy
5. Trauma: Recent injury to neck, shoulder, arm?
6. Position-dependent: Worse with certain positions = compression/entrapment
7. Night symptoms: Carpal tunnel wakes patient at night
8. Previous episodes: Prior neurological symptoms that resolved = MS
9. Motor involvement: Any weakness, clumsiness, grip loss?
10. Other symptoms: Leg symptoms, bladder/bowel, vision changes, balance = CNS

Examination Findings to Elicit

Investigations

Most Likely Diagnoses in a 27-Year-Old Male

1. Cervical disc herniation (C6 or C7 radiculopathy) - common in young men, especially with heavy lifting or poor posture
2. Peripheral nerve entrapment - ulnar at elbow, median at wrist
3. Brachial plexus neuropathy (Parsonage-Turner) - look for preceding severe shoulder pain
4. Multiple sclerosis - sensory symptoms are the most common first presentation
5. Thoracic outlet syndrome - compression of brachial plexus between clavicle and 1st rib

• Bradley and Daroff's Neurology in Clinical Practice, p. 474
• Localization in Clinical Neurology 8e, p. 228
• Tintinalli's Emergency Medicine, p. 1427
• Neuroanatomy through Clinical Cases 3e

Vital Signs Interpretation - 27-Year-Old Male with Right Arm Sensory Loss

Vitals at a Glance

1. Blood Pressure: 150/100 mmHg

What this BP tells us clinically:

• Hypertensive encephalopathy / cerebrovascular event: BP driving a small infarct or TIA affecting the sensory cortex or white matter tracts. Though 150/100 is not extreme, it can cause end-organ damage, especially in someone with previously undiagnosed and uncontrolled hypertension.

  "It is important to distinguish between hypertensive encephalopathy, in which lowering of BP is clearly indicated, and ischemic stroke with hypertension, in which urgent lowering of BP may not be warranted." - Comprehensive Clinical Nephrology 7e

• Acute stroke with reactive hypertension: In acute ischemic stroke, the brain auto-raises BP to maintain perfusion to the ischemic penumbra. A presenting BP of 150/100 in a young person with focal neurology must raise the possibility of an acute vascular event.

• If ischemic stroke is suspected and no thrombolysis planned: do NOT lower BP unless SBP >220 or DBP >120 mmHg
• If thrombolysis is being considered: bring BP below 185/110 mmHg before administering tPA
• At 150/100, aggressive BP lowering would be harmful in acute stroke - it reduces perfusion to the ischemic penumbra
• "Patients not receiving thrombolytic agents should have antihypertensive medications withheld unless the SBP is greater than 220 mmHg or the DBP is greater than 120 mmHg" - Comprehensive Clinical Nephrology 7e, p. 580

2. SpO2: 98% - Normal

• Peripheral and central perfusion is adequate
• No respiratory compromise
• Pulmonary embolism (which can cause arm symptoms via paradoxical embolism through a PFO) remains possible but less likely given normal SpO2
• No hypoxia driving the tachycardia

3. Heart Rate: 110 bpm - Tachycardia

Causes to consider:

Integrated Clinical Picture

Right arm sensory loss + BP 150/100 + HR 110 + SpO2 98%

1. Cocaine or stimulant use - causes stroke, HTN, and tachycardia simultaneously; very common in this age group - ask directly and non-judgmentally
2. Pheochromocytoma - episodic catecholamine surge
3. Cardioembolism from arrhythmia (AF, SVT)

Immediate Action Plan

1. ECG immediately - rule out AF, arrhythmia (explains both tachycardia and embolic arm sensory loss)
2. Non-contrast CT head - rule out hemorrhage
3. Blood glucose stat - hypoglycemia mimics stroke
4. Toxicology screen (urine) - cocaine, amphetamines
5. MRI brain + DWI - detect acute ischemia if CT negative
6. MRI cervical spine - if no vascular lesion found
7. Renal function, urinalysis - secondary hypertension workup
8. TFTs (thyroid) - hyperthyroidism
9. Do NOT aggressively lower BP unless >220/120 - risk of worsening ischemia
10. Monitor HR - if irregularly irregular, consider rate control

Key Message

Do not treat the BP in isolation. In a young man with focal neurology, BP 150/100 and HR 110 together are a signal to find the underlying cause, not just numbers to be corrected. The SpO2 of 98% is the only fully reassuring vital here.

• Comprehensive Clinical Nephrology 7e, p. 580
• Swanson's Family Medicine Review

Treatment Plan - 27-Year-Old Male, Right Arm Sensory Loss, BP 150/100, HR 110, SpO2 98%

PHASE 1 - Immediate Emergency Management (First 30-60 Minutes)

A. Stabilize and Monitor

B. Blood Pressure Management (Critical)

DO NOT lower the BP - this level is not an indication for treatment in acute stroke/TIA

• Per AHA/ASA guidelines: withhold antihypertensives unless SBP >220 or DBP >120 in ischemic stroke (not on tPA)
• If tPA is being considered: bring BP to <185/110 before giving it, then maintain <180/105 for 24 hours post-tPA
• At 150/100 this patient is already within the tPA-safe range if eligible
• Comprehensive Clinical Nephrology 7e, p. 580

C. Tachycardia (HR 110)

• ECG now - if AF confirmed: rate control (e.g., metoprolol) + anticoagulation plan
• If sinus tachycardia: treat the cause (pain, anxiety, dehydration, hyperthyroidism, stimulants)
• Do NOT give IV beta-blockers empirically if stroke is suspected - may drop BP and worsen ischemia

PHASE 2 - Definitive Treatment by Diagnosis

IF ISCHEMIC STROKE (CT head normal, DWI positive)

Step 1 - Is the patient eligible for IV tPA (Alteplase)?

• Symptom onset within 4.5 hours (time of onset must be known)
• Age ≥18 (yes - 27 years old)
• NIHSS documented
• No hemorrhage on CT
• BP <185/110 (currently 150/100 - eligible)
• No recent surgery, bleeding, anticoagulant use

• Admit to stroke unit/ICU after tPA
• Monitor BP every 15 min for 2 hours, then every 30 min for 6 hours, then hourly for 16 hours

Step 2 - Mechanical Thrombectomy (if large vessel occlusion on CTA)

• For large vessel occlusion: up to 24 hours from symptom onset with favorable perfusion imaging
• Requires transfer to comprehensive stroke center if not available
• Harrison's 22e: "Creating regional systems of care whereby stroke patients are first evaluated at acute stroke-ready hospitals... then transferred to thrombectomy-capable centers... is an effective strategy"

Step 3 - Antiplatelet Therapy (if NOT receiving tPA)

• Aspirin 300 mg loading dose orally/per NGT immediately (after hemorrhage excluded)
• Then aspirin 75-100 mg/day maintenance
• For minor stroke (NIHSS ≤3): add clopidogrel 300 mg loading dose, then 75 mg/day
• Dual antiplatelet (aspirin + clopidogrel) for 21 days - proven to reduce early recurrent stroke (POINT + CHANCE trials)

  "Early and short-term clopidogrel-aspirin treatment was associated with a reduction in the risk of major ischemic events... benefit confined to first 21 days after minor ischemic stroke or high-risk TIA" - Rosen's Emergency Medicine

Step 4 - If AF confirmed (cardioembolic stroke)

• Anticoagulate: DOAC (apixaban, rivaroxaban, dabigatran) preferred over warfarin in young patients
• Start within 4-14 days depending on stroke size (risk of hemorrhagic transformation)
• Do not use aspirin + anticoagulant together routinely

Step 5 - Supportive Acute Stroke Care

IF TIA (CT/MRI normal, symptoms resolved)

• Do NOT discharge from ED - stroke risk is up to 10% within 2 days
• Calculate ABCD2 score:

• Aspirin 300 mg + Clopidogrel 75 mg (dual antiplatelet) - start immediately
• Statin (atorvastatin 40-80 mg) - start in ED
• Urgent MRI brain + MRA neck/circle of Willis within 24h
• Admit or urgent TIA clinic within 24 hours
• If AF found: anticoagulation

IF CERVICAL RADICULOPATHY (MRI shows disc herniation)

IF PERIPHERAL NERVE ENTRAPMENT (NCS/EMG confirms)

IF MULTIPLE SCLEROSIS (MRI shows demyelinating plaques)

Secondary Prevention (All Stroke/TIA Patients)

"Patient care in stroke units followed by rehabilitation services improves neurologic outcomes and reduces mortality." - Harrison's Principles of Internal Medicine 22e

Summary Algorithm

Right arm sensory loss + BP 150/100 + HR 110
          |
   CT Head (STAT)
   /              \
Hemorrhage       No hemorrhage
   |                   |
Neurosurgery     tPA eligible? (onset <4.5h)
consult           Yes → Alteplase 0.9 mg/kg IV
                  No → Aspirin 300mg + Clopidogrel
                          |
                    MRI DWI + MRA
                    /          \
              Ischemic        TIA/Normal
              stroke          Dual antiplatelet
              Thrombectomy    Statin, admit 24h
              if LVO          outpatient workup

• Harrison's Principles of Internal Medicine 22e, p. 3486
• Rosen's Emergency Medicine, p. 1442
• Comprehensive Clinical Nephrology 7e, p. 580

Inj. Diclofenac IM - Can It Be Given to This Patient?

Short Answer: Use with Extreme Caution - Mostly NOT Recommended Here

Drug Profile: Diclofenac IM

Why It Is Problematic in THIS Patient

1. Possible Acute Stroke / TIA - MAJOR Concern

"The FDA warns that all non-aspirin nonsteroidal anti-inflammatory drugs increase the risk of myocardial infarction or stroke."

• Morgan & Mikhail's Clinical Anesthesiology 7e

• Diclofenac is a non-selective COX inhibitor - it inhibits platelet aggregation (COX-1 dependent thromboxane A2)
• In an acute ischemic stroke, the patient will be given aspirin ± clopidogrel as the cornerstone treatment
• Adding diclofenac to antiplatelet therapy increases bleeding risk significantly
• NSAIDs also competitively interfere with aspirin's irreversible COX-1 binding - diclofenac taken before aspirin can block aspirin's antiplatelet effect
• COX-2 inhibition by diclofenac also promotes a prothrombotic state (reduces prostacyclin without reducing thromboxane) - exactly the opposite of what this patient needs

2. Hypertension - Significant Concern

• NSAIDs cause sodium and water retention via prostaglandin inhibition in the kidney
• This raises blood pressure - counterproductive when BP is already 150/100 and you need NOT to aggressively raise or lower it
• "COX-2 selective NSAIDs may elevate blood pressure and increase the frequency of thrombotic cardiovascular events" - Braunwald's Heart Disease
• Non-selective NSAIDs like diclofenac share this risk

3. No Confirmed Pain Indication Yet

• This patient's chief complaint is sensory loss (numbness), not severe acute pain
• Diclofenac IM is indicated for moderate-severe pain - if there is no significant pain complaint, giving a systemic NSAID with its full risk profile is not justified

When Could Diclofenac IM Be Considered?

• Stroke / TIA is ruled out (CT + MRI negative, no vascular event)
• Diagnosis is confirmed as musculoskeletal (cervical radiculopathy, nerve root pain, myofascial)
• Patient has significant pain requiring parenteral analgesia
• No antiplatelet therapy has been started
• No renal impairment, no peptic ulcer disease, no cardiovascular contraindication

Safer Analgesic Alternatives Right Now

Paracetamol 1g IV is the safest first-line analgesic in a patient with suspected neurological event + hypertension + tachycardia

Summary

• Morgan & Mikhail's Clinical Anesthesiology 7e, p. 526
• Braunwald's Heart Disease

✅ Inj. PCT (Paracetamol) 1000 mg IV - Excellent Choice

Drug Details: IV Paracetamol 1000 mg

"A maximal adult (>50 kg weight) dose of 1g is infused to a maximum total dose of 4g/d."

• Morgan & Mikhail's Clinical Anesthesiology 7e

Why It Is the Right Drug for This Patient

"It does not cause gastric irritation and clotting abnormalities."

• Morgan & Mikhail's Clinical Anesthesiology 7e

Mechanism of Action

• Centrally acting analgesic - inhibits COX centrally in the brain and spinal cord
• Weak/negligible peripheral COX inhibition
• Also acts on the endocannabinoid system and serotonergic descending pathways
• Has antipyretic action (useful if fever develops - fever worsens ischemic brain injury)
• No anti-inflammatory effect at therapeutic doses

How to Administer

Inj. Paracetamol 1000 mg (100 mL, 10 mg/mL solution)
→ IV infusion over 15 minutes
→ Repeat every 6-8 hours
→ Max 4 doses (4g) per 24 hours

• Use a dedicated IV line or flush before/after
• No dilution needed - comes ready to infuse
• Check expiry and clarity of solution before use

One Caution to Remember

What to Watch After Giving

• Pain relief expected in 15-30 minutes after infusion
• Monitor BP and HR after infusion - if tachycardia settles with pain relief, it was likely pain-driven (reactive sympathetic response)
• If HR does not settle after pain is controlled - investigate further (AF, pheochromocytoma, hyperthyroidism, stimulant use)
• Continue neurological monitoring - don't let analgesic comfort delay the urgent CT head and investigations

Next Step After PCT

1. CT head (non-contrast) - urgent, rule out hemorrhage
2. ECG - rule out AF causing the tachycardia
3. Blood glucose - stat
4. MRI brain + cervical spine - definitive workup
5. NCS/EMG referral - if no central lesion found

• Morgan & Mikhail's Clinical Anesthesiology 7e, p. 526

Assessment: DNS 500 mL + Inj. Pan 40 + Inj. Ondem

1. DNS 500 mL (Dextrose Normal Saline)

⚠️ CAUTION - Not the Ideal Fluid Here

In acute ischemic stroke, maintain blood glucose 140-180 mg/dL and avoid hyperglycemia. Glucose-containing IV fluids are not recommended as routine hydration.

• Barash's Clinical Anesthesia / Harrison's 22e

✅ What to Use Instead:

2. Inj. Pantoprazole 40 mg IV (PPI)

✅ YES - Appropriate and Recommended

• This patient will be started on aspirin ± clopidogrel for stroke/TIA prevention
• Dual antiplatelet therapy significantly increases risk of GI bleeding and peptic ulceration
• A PPI (pantoprazole 40 mg) co-prescribed with antiplatelet therapy is standard of care to protect the gastric mucosa
• Also covers any nausea/vomiting component from the neurological event or medications

3. Inj. Ondansetron (Ondem) 4 mg IV

✅ YES - Appropriate, with one note

• Nausea and vomiting are common in acute neurological events (especially brainstem/posterior circulation involvement, raised ICP)
• Also covers medication-induced nausea (paracetamol, antiplatelet drugs)
• Ondansetron is safe cardiovascularly at standard doses, does not raise BP, does not affect platelets
• Does not sedate - important as you need to monitor neuro status

• Ondansetron can cause mild QT prolongation - if ECG shows prolonged QTc, consider metoclopramide 10 mg IV instead (but metoclopramide has extrapyramidal side effects)
• Avoid high doses (>32 mg/day) in any patient

Summary Table

Revised IV Order Suggestion

1. Inj. Normal Saline 0.9%    500 mL IV   over 4-6 hours  (replace DNS)
2. Inj. Pantoprazole 40 mg    IV           once daily
3. Inj. Ondansetron 4 mg      IV           every 8h PRN (for nausea)
4. Inj. Paracetamol 1000 mg   IV infusion  every 8h       (already started)
5. Tab. Aspirin 300 mg         oral/NGT     stat           (after CT confirms no hemorrhage)

BP Now 128/90 - What Does This Tell Us?

• The earlier 150/100 may have been a reactive/stress response to pain and anxiety
• Now settling to 128/90 after paracetamol and initial management - a good sign
• Still in the pre-hypertensive/Stage 1 range - continue monitoring
• Do NOT start antihypertensives yet - still within safe range for stroke management
• Recheck BP every 15-30 minutes and trend it

GRBS 100 mg/dL - Interpretation

✅ Normal - Reassuring

What This Tells You

1. Hypoglycemia is RULED OUT

• Blood glucose <60 mg/dL can mimic stroke (focal weakness, numbness, confusion)
• At 100 mg/dL, hypoglycemia is definitively excluded as the cause of this patient's right arm sensory loss
• No dextrose supplementation needed

2. Confirms DNS Was the Wrong Fluid Choice

• Glucose is already 100 mg/dL (normal-high normal)
• Giving DNS would push glucose higher unnecessarily
• This further confirms NS 0.9% is the correct IV fluid for this patient
• Target glucose in stroke management: 140-180 mg/dL - he is currently well within range

3. Diabetes Less Likely (as primary cause)

• A random glucose of 100 mg/dL makes uncontrolled diabetic neuropathy unlikely as the cause of arm sensory loss
• However, a formal fasting glucose + HbA1c should still be done as part of risk factor assessment

Updated Vitals Summary So Far

Action Points

✅ Yes — Start Inj. PCT 1000 mg IV Right Now

Order:

Inj. Paracetamol (PCT) 1000 mg
→ IV infusion over 15 minutes
→ Repeat every 8 hours
→ Max 4g (4 doses) in 24 hours

What to Watch After Infusion

• Pain/discomfort relief expected in 15-30 min
• HR may come down if tachycardia was pain/anxiety-driven - recheck HR after 30 min
• BP - recheck after infusion; PCT will not lower it significantly but pain relief may help
• Neurological status - keep monitoring arm numbness, any new symptoms

While PCT is Running - Do These in Parallel

🔄 Updated Clinical Picture - Major Development

Current Status

This Pattern is HIGHLY Suggestive of...

Migraine with Aura - Most Likely Diagnosis Now

"Migraine with aura... Sensory deficits can involve an ipsilateral arm or periorbital numbness or tingling... The sensation has a marching characteristic. Motor deficits can be similar in that the deficits spread from one area to another."

• Textbook of Family Medicine 9e

AURA phase (20-60 min)          →        HEADACHE phase
Right arm numbness + stiffness  →   Left-sided throbbing headache
(Contralateral to headache)          (now developing as aura resolves)

• The right arm sensory symptoms = aura (focal neurological deficit)
• As the aura resolves, the headache begins on the ipsilateral (left) side to the brain lesion (contralateral to the body symptoms)
• Aura typically lasts 20-60 minutes, then headache follows
• The improvement in numbness as headache starts = classic aura-to-headache transition

Why This Changes the Diagnosis

However - Still Cannot Skip CT Head

1. Subarachnoid hemorrhage (SAH) - can present with sudden headache + focal neuro symptoms
2. Hemorrhagic stroke - must rule out before any triptans or aspirin
3. Migrainous infarction - rare but real - migraine can cause actual infarction
4. First-ever episode - if this is the first time this patient has had these symptoms, it MUST be imaged - never diagnose first migraine with aura without ruling out vascular event

"Neuroimaging evidence of a cerebral infarct associated with a migraine is indicative of migrainous infarction." - Textbook of Family Medicine 9e

Ask These Questions RIGHT NOW

Revised Differential (Most → Least Likely Now)

Immediate Management Update

✅ Continue Current Drugs

• Inj. PCT 1000 mg IV - also helps the headache ✅
• Inj. Pan 40 mg IV ✅
• Inj. Ondem 4 mg IV - especially useful now as nausea may accompany migraine ✅
• NS 0.9% IV - continue hydration ✅

🔴 Do NOT Give Yet (Until CT done)

• Triptans (sumatriptan) - contraindicated if vascular event not excluded
• Ergotamine - vasoconstrictive, contraindicated in suspected vascular cause
• Aspirin - hold until hemorrhage excluded on CT

🔴 Urgent - CT Head NOW

• Rule out hemorrhage, SAH, infarct
• If CT normal → MRI brain with DWI (rules out ischemic stroke/migrainous infarction)
• If both normal + classic history = Migraine with Aura confirmed

🟡 If Migraine Confirmed After CT Normal:

Bottom Line

This clinical evolution - right arm sensory aura resolving → left-sided headache developing - is the textbook pattern of migraine with aura in a 27-year-old. This is now the leading diagnosis. But CT head is non-negotiable before treating as migraine. Get the scan now.

• Textbook of Family Medicine 9e, p. 1217