Teaching NeuroImages: Headache with pulsatile tinnitus.

A 62-year-old woman presented with 3 months of insidious-onset, persistent headache focused around the left temple. She had left-sided pulsatile tinnitus and the affected area was warm to touch. Neurologic examination, including hearing, was normal with no objective bruit. A minimally elevated alkaline phosphatase (282 U/L) was the only blood abnormality. Imaging (figure) revealed osteoporosis circumscripta: the acute lytic phase of Paget disease. Although frequently asymptomatic, associated bone pain may present as headache. The vascularity of the petrous lesion explains the tinnitus. Treatment with antiresorptive agents modestly improved the headache and may prevent ensuant neurologic complications attributed to the proliferative phase.1 DISCLOSURE Dr. Armstrong reports no disclosures. Dr. Downer has received funding for travel from eV3 Neurovascular Inc. Dr. Anslow receives publishing royalties for Neurological Case Histories (Oxford University Press, 2007). Dr. Evans reports no disclosures. Dr. Ebers serves on the editorial boards of the International Multiple Sclerosis Journal and Multiple Sclerosis and as Section Editor for BMC Medical Genetics; has received funding for travel or speaker honoraria from Bayer Schering Pharma, sanofi-aventis, Roche, and UCB; has served as a consultant to Biopartners, Bayer Schering Pharma, Howrey LLP, Heron Health, and Eli Lilly and Company; and receives research support from Bayer Schering Pharma, the Multiple Sclerosis Society of the United Kingdom, and the Multiple Sclerosis Society of Canada Scientific Research Foundation.