Anamnesis

Identification: Gender/Age: Male, 19 years

Medical History: No previous comorbidities

Family History: Mother diagnosed with CM1 (asymptomatic)

History of Present Illness (HPI): Main symptom: Occipital headache for 4 months

Pain characteristics:

Location: Bilateral suboccipital with cervical radiation

Character: Throbbing and pressing

Intensity: 6-7/10

Duration: 15-30 minutes, 2-3 episodes weekly

Triggers: Physical exertion, laughter, and cervical flexion

Improvement: Rest in supine position

Associated symptoms:

Occasional pulsatile tinnitus

Mild dysphagia for solids

No motor or sensory deficits

Physical/Neurological Examination:

General: Well-nourished, normotensive

Neurological:

Mild horizontal nystagmus

Brisk reflexes in the lower limbs

Positive Romberg's test

No papilledema or focal deficits

Complementary Examinations:

Magnetic Resonance Imaging of the Brain and Cervical Spine:

Tonsillar herniation of 7 mm

Mild distortion of the fourth ventricle

Absence of syringomyelia

MR Angiography: Excludes cerebral venous thrombosis

Report this case — e.g. suspected re-identification risk.