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To the Editor:
Dr. Kim1 presents a case of a woman with sudden-onset headache and diplopia following a neck massage who is ultimately diagnosed with idiopathic intracranial hypertension (IIH). The case is presented as an exercise in clinical reasoning.
Although the final diagnosis is incontrovertible, the discussant fails to demonstrate appropriate clinical reasoning in arriving at the diagnosis. Dr. Kim states that in a young obese patient with sudden severe headache and diplopia without other focal neurologic signs, IIH “should be the top differential.” We believe that clinical reasoning should direct the clinician to first exclude vertebral artery dissection (headache and focal neurologic signs after neck manipulation) and perhaps cerebral aneurysm (sudden-onset severe headache and diplopia). IIH …
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