Seizure After Sudden Headache in a 16-Year-Old Cyclist

Payman Vahedi, MD; Zahra Mohajernezhad, MD; Mohammad Faraji-Rad, MD


March 25, 2022

Physical Examination and Workup

Upon physical examination, the patient is a normal-appearing teenager, but she is agitated due to her headache. She has a regular heart rate of 65 beats/min, her blood pressure is 165/95 mm Hg, and her oral temperature is normal at 98.6°F (37°C). The general physical examination reveals no abnormalities in the head, neck, chest, abdomen, or extremities.

A thorough neurologic examination is performed, which reveals decreased visual acuity in each eye to 6/10 (or about 20/30 US Standard). Ophthalmoscopy reveals papilledema, venous engorgement, and a diminished venous pulse. Bilateral sixth cranial nerve palsy is evident. Other neurologic examinations, including sensory and motor examinations, deep tendon reflexes, and cerebellar tests, are all within normal range.

During the initial assessment of the patient in the emergency department, she develops a generalized tonic-clonic seizure, which is immediately controlled with intravenous diazepam. Her blood pressure rises to 175/100 mm Hg, and her heart rate is 60 beats/min after the convulsion. A repeat neurologic examination reveals bilateral extensor plantar reflexes and midsized pupils with slight reaction to light. After initiating a loading dose of intravenous phenytoin, an urgent CT scan of the head is performed (Figure 1).

Figure 1.


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