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Not just another headache

01 September 2009

Mr Q, a 40-year-old man, booked an emergency appointment to see Dr A. He presented with a severe headache. He told Dr A that it had come on suddenly and was very worried as to the cause, as he had not experienced a headache like it before. He had a history of tension headaches and had been seen and investigated by a neurologist during the past year to rule out other causes of his recurrent headaches. Mr Q also had a long history of anxiety and panic attacks.

Dr A documented the description of the headache and performed a neurological examination which was documented as normal. No papilloedema was noted. Mr Q was found to be systemically well and apyrexial with no history of fevers, rash nor photophobia. Dr A recorded that Mr Q appeared tremulous and anxious, and noted his blood pressure was raised. Dr A diagnosed an anxiety attack and provided reassurance and a prescription for diazepam, to help settle the acute anxiety.

Two days later, Mr Q requested a home visit from Dr A, who attended within the next hour. Mr Q reported a worsening headache. He had also started vomiting overnight and was now experiencing blurred vision. Dr A again performed a neurological examination, and found no focal signs. Mr Q’s blood pressure was raised at a similar level to the previous assessment.

Dr A still felt that the diagnosis was likely to be anxiety. However, the new symptoms of vomiting and visual disturbance were suggestive of possible raised intracranial pressure. These red flag symptoms, and the fact that the headache had persisted, despite reassurance and a small dose of benzodiazepine, led Dr A to organise urgent admission and assessment by the medical team.

Soon after admission, Mr Q lost consciousness and collapsed. An urgent CT scan showed a subarachnoid haemorrhage. Mr Q underwent emergency surgery to relieve the raised intracranial pressure. Following the surgery Mr Q was left with cognitive deficit and word-finding difficulties.

After his discharge Mr Q began a claim against Dr A for failing to diagnose the haemorrhage.

Expert opinion

The GP experts agreed that Dr A took an appropriate history and this was well documented. It was felt he responded adequately by questioning his diagnosis at the second presentation, and admitting Mr Q in response to the new red flag symptoms. The GP experts supported the standard of care provided by Dr A and the claim was successfully defended.

Learning points

  • Headache is a common symptom. It is important to remember the red flag symptoms that point to a serious cause. It is good practice to routinely document the presence or absence of these symptoms in patients presenting with headache. 
  • It is vital for any doctor to keep an open mind to differential diagnoses and to be prepared to challenge their own previous diagnosis (or that of another doctor) if the patient’s complaint does not follow the expected course. 
  • Patients with anxiety can often present with physical symptoms. Sometimes these will be a physical expression of emotional stress – somatization. However, the converse can be true in that physical pain and illness can cause anxiety. It is important to bear this in mind when patients present with anxiety as well as physical symptoms. 
  • When assessing a patient with a history of anxiety disorder be careful to take a fresh and objective approach. 
  • Good documentation should reflect the thought processes involved in arriving at a diagnosis or differential diagnoses. It should include important negatives as well as positive findings in the history and examination.
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