Beware the middle-aged migraine: internal carotid artery dissection mimicking migraine in the emergency department

Description

A 53-year-old woman presented to the emergency department (ED) with a 3-day history of gradual onset left-sided headache localised behind the left eye. This was associated with visual disturbance in the left eye described as 'zig-zag lines'.

She had never suffered from headache before and her only significant medical history was of hysterectomy and subsequent provoked pulmonary embolus. She was not taking any regular medication.

Initial assessment was completed by an Foundation Year 2 doctor (FY2) in ED. There was no evidence of focal neurological deficit. A diagnosis of migraine with aura was reached and the patient was discharged home with a short course of non-steroidal anti-inflammatories and paracetamol. She was advised to return to the ED if her symptoms failed to improve or in the event of new symptoms developing.

She returned the following day. The patient was again assessed by an FY2 in ED. The description...

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