Questions.
1. Write down your list of differential diagnoses.
This is clearly not a common presentation in an 8 year old girl. In reality we were very worried about her as the level of distress was very high, and was in fact bordering on the agitated cerebral patient. Our intial approach was to control the pain through a combination of oral and parenteral opiates. This allowed a more thorough examination (completely normal) and a full set of observations (again normal).

In terms of differentials it is is often difficultin children for them to express their severity and the temporal relationships of their symptoms accurately when distressed.

Our differentials were
1. Migraine. History fits well, but no past history and agitation unusual.
2. Subarachnoid, but rare at this age
3. Encephalitis, but apyrexial, neurology before headache and no overt meningism.


2. How are you going to investigate this girl?
We checked the BM and took routine bloods (all normal), and got an urgent CT scan (aided by IV Morphine). The CT was normal and by this time her headache and symptoms were ra[idly resolving. Six hours later when reviewed on the ward she was entirely back to normal and a full history form the parents revealed a history of fairly severe headaches at weekends in the preceding months.

A final diagnosis of neuralgic migraine was made and she was referred for neurology review as an out patient.