A Circus of Pain - NYTimes.com It was a cool fall day, but the sun seemed extremely bright as the young man helped guide nine circus elephants to their new pens. Even though the man was wearing sunglasses, the morning sun reflecting off the metal equipment felt like a knife cutting into his right eye. His head throbbed behind the eye, and an occasional tear rolled down his cheek. When the animals were finally secured, he returned to his trailer. "O.K., I do need a doctor," he said to his girlfriend. His hand was cupped over the side of his face. Right now. Unlike Anything Else It was the worst headache of his life, the 25-year-old patient told the doctor in the emergency room of Highland Hospital in Rochester. It started five days earlier when the circus was in Connecticut. At first it wasn't a big deal. He would take a couple of aspirin, and it would disappear. But when the medicine wore off, the headache was still there. In fact, each time it seemed just a little worse. That morning, when he got out of bed, the pain was unbearable. He took aspirin, Advil, Tylenol. Nothing put a dent in it. The pain was sharp and on the right. It felt as if someone were slamming a door inside his head. He'd had the occasional headache but never something like this. He didn't smoke, rarely drank and took no medications. He had no recent head trauma, though he was head-butted by a zebra a few years ago. That hurt - it broke his glasses - but not this much. His mother had migraines, and perhaps that's what this was. Maybe, the doctor said, though a week was a long time for a migraine. First, Worst or Cursed For doctors, a description of a headache as the worst is a red flag. We worry about headaches described as the first (for someone who doesn't have headaches) or the worst (for someone who does) or those that are ""cursed"" by the presence of other symptoms like weakness or confusion. He didn't have other symptoms, but the doctor was concerned because he called it the worst. Abnormalities The doctor ordered a painkiller and blood tests to look for signs of infection or inflammation. She also ordered a CT scan of the head to look for a tumor or evidence of blood. The blood tests were normal. The CT was not. Within the brain, there are compartments where spinal fluid is made. The fluid then circulates around the brain and spinal cord and is reabsorbed. Two of these compartments, known as the lateral ventricles, are usually mirror images of each other. But in this patient, the ventricle on the right, where his headache was located, was much larger than the one on the left. That suggested there might be a blockage in the circulation of the spinal fluid on the right side, which was causing pressure to build. That could certainly cause a headache - and permanent damage if not addressed quickly. Pressure Even before the E.R. doctor saw the CT scan, she called neurology for help in figuring out this patient's terrible headache. The neurology resident examined the patient and his CT scan, but it wasn't clear to him how the pieces fit together. If the asymmetry were caused by an obstruction, the patient should have symptoms associated with increased brain pressure - like nausea - but he didn't. The resident knew that he didn't have enough data to make a diagnosis. Watching the patient over time would give him more. If there was a blockage in his brain, he should begin to feel nauseated and weak. If he didn't, it was very unlikely that the asymmetry reflected a blockage. The patient was admitted to the hospital, where nurses were to examine him every four hours to look for any change. No Relief Overnight the headache became worse, despite the use of several powerful painkillers. By morning the patient was exhausted from the pain and nearly incoherent from the narcotics. He never, however, developed symptoms of increased pressure in his brain. The neurologist speculated that this was a migraine and recommended he go home and follow up as an outpatient. The neurosurgeons weren't so sure there wasn't an obstruction. The patient's worsening pain was worrisome. They recommended an M.R.I. If there was a change in the size of the ventricle, when compared with the CT, they could drill a small hole into his skull and relieve the pressure. The Tincture of Time