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Left-Sided Headache in a Salvadorian Woman.

CASE PRESENTATION A 30-year-old Salvadorian woman presented as a new patient to a free student-run outpatient clinic in New York with a 1-year history of severe, sudden-onset, left-sided headaches and eye pain. The headacheswere rated as 7/10 in severity, occurred 1 to 2 times per week, and were associated with photophobia and phonophobia. The headaches were worst in the morning, occasionally woke the patient from sleep, and were described by the patient as a sensation that “my head is exploding.” Sleep and ibuprofen 400mg PRN (as needed) provided moderate relief. The patient previously sought treatment at an outside clinic where she was diagnosed with migraine headaches and prescribed naproxen with some relief. She denied a history of trauma to the head, although she did reveal previous psychological trauma associated with sexual violence. The patient denied fevers, chills, weight changes, neck stiffness, visual changes or disturbances, nausea, vomiting, or known seizures. She took no medications regularly and was allergic to penicillin. Medical history was remarkable for intermittent asthma and prior appendectomy. The patient reported no family history of headaches or other neurological disorders. She denied tobacco, alcohol, or illicit substance use. The patient had lived in the United States for a decade, but had traveled back and forth from El Salvador on several occasions, most recently 5 years ago. She denied known consumption of undercooked meats, but admitted to eating street foods, including meats, while in El Salvador. She owned pigs in her house in El Salvador. On physical examination, the patient was hypertensive at 145/85 mm Hg; vital signs were otherwise within normal limits. Body mass index was 29.6 kg/m. She was in no acute distress; was alert and oriented to person, place, and time; and exhibited no neurological deficits. Cranial nerves II to XII were intact, sensation to touch was preserved bilaterally, strength was 5/5 in all limbs, deep tendon reflexes were 2+ bilaterally, regular and tandem gait were normal, and there were no signs of dysdiadochokinesia or dysmetria. A small urticarial rash was noted on the left upper back. The remainder of the examination was unremarkable. Given the severity, new onset, unilaterality, and tempo of the patient's headaches, a magnetic resonance imaging (MRI) scan of the brain without and with intravenous contrast was performed to rule out mass lesions or intracranial hemorrhage. This study (Fig. 1) revealed 2 cystic-appearing parenchymal masses of 1.2 and 1.7 cm in the left inferior insular cortex and left anterior superior