A previously well 24 year old man presented to the emergency department with a two week history of worsening temporal headache and non-specific coryzal symptoms. Due to the protracted course of his symptoms he was initially triaged to minors. On medical assessment, it emerged he had consulted his general practitioner earlier in the course of the illness. He had been prescribed and had completed a course of oral amoxicillin. Twenty four hours before attendance, he developed persistent vomiting and an occipital headache. He complained of neck pain and also of photophobia.

On examination, he had a temperature of 38 °C, and was supporting his head in extension with his hands, while vomiting continuously. He could not tolerate funduscopy because of the photophobia, and his headache worsened on lying down. There were no other significant findings.

Due to his presentation, his …