A 44-year-old woman complains bitterly of severe headache that has been present for several weeks and has not responded to the usual over-the-counter headache remedies. She locates the headache to the center of her head. It is pretty much constant but is worse in the mornings. She has no other neurologic signs or symptoms. She has had “tension headaches” in the past, but she says that those were located in the back of her head and felt different from the present pain. She is currently under considerable stress because she has been unemployed since undergoing modified radical mastectomy for T3, N1, M0 breast cancer 2 years ago. She had several courses of post-operative chemotherapy, which she eventually discontinued because of the side effects. Which of the following is the most appropriate next step in diagnosis?
A. CT scan of the head
B. Psychiatric evaluation
C. Skull x-rays
D. Aortic arch arteriogram
E. Lumbar puncture
Explanation: The correct answer is A. Persistent headache in a patient with recent history of breast cancer (particularly node-positive) is brain metastasis until proven otherwise. The only acceptable course of action is to take a look (radiologically, of course), and the cheapest and most reliable way would be a CT scan. For primary brain tumors, the MRI is favored; however, to show the presence of metastasis, an MRI is not needed. Despite the history of tension headaches and current job worries, psychiatric causes (choice B) are far down the line in the differential diagnosis. Skull x-rays (choice C) are almost a vanishing test. They may still show linear skull fractures when you are looking for them, but they would certainly not show intracranial masses. Vascular studies (choice D) were, at one time, the only reliable way to rule out intracranial tumor, but the CT scan displaced them. We still use them to define vascular lesions, which this vignette does not suggest. Lumbar puncture (choice E) would not diagnose a tumor and would subject the patient to the risk of herniation of the brainstem. Save that test for patients with meningitis.