[Clinical thinking and decision making in practice. A student with sudden headache]

A previously healthy man aged 18 years suddenly developed a severe headache, followed by nausea, vomiting, fever. During the following weeks a left-sided hemiparesis developed. CT of the brain revealed a pansinusitis and a frontal epidural empyema. A few days after surgical drainage his condition deteriorated and subsequent CT showed a right-sided subdural empyema. This was surgically evacuated and followed by long-term high-dose intravenous antibiotic therapy. The patient made a complete recovery. A sudden severe headache can be caused by an intracranial infection and intracranial pus collections can occur in the subdural as well as in the epidural space. Epidural empyema is a limited disease with relatively mild symptoms and a favourable prognosis, whereas subdural empyema may rapidly spread and cause severe disease with a poor prognosis. Quick antibiotic treatment and surgical drainage are required.