Neurology Question 58

A 26-year-old woman is evaluated for progressively worsening headaches that began intermittently 6 months ago and became daily 3 months ago. The patient describes bilateral “vise-like” pain that is steady, moderate in intensity, and unaffected by physical activity. She also has experienced brief, temporal, sharp pains and a few episodes of transient binocular visual dimming. The headaches are accompanied by moderate neck stiffness and mild photophobia but no nausea, phonophobia, or focal neurologic symptoms. She has polycystic ovary syndrome diagnosed 2 years ago and treated with metformin and a combined oral contraceptive but no personal or family history of headache. The patient takes no other medication or supplement. On physical examination, blood pressure is 124/80 mm Hg and pulse rate is 72/min; BMI is 30. Partial left palsy of the abducens nerve (cranial nerve VI) is noted. A funduscopic photograph is shown. An MRI is normal. Analysis of cerebrospinal fluid obtained on lumbar puncture shows an opening pressure of 350 mm H2O.

Which of the following is the most appropriate treatment?

A Acetazolamide

B Amitriptyline

C Epidural blood patch

D Optic nerve sheath fenestration

E Spironolactone

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