The correct answer is E. This presentation is concerning for venous sinus thrombosis. MRV is the best noninvasive test to confirm this diagnosis. If the MRI/MRV is negative, then she should have a lumbar puncture to rule out idiopathic intracranial hypertension (pseudotumor cerebri).
Intravenous heparin (choice A) is the usual treatment for a venous sinus thrombosis, however, the diagnosis should be confirmed first if possible. Therefore, a brain MRI and MRV is the most appropriate next step in management.
A neurosurgical consult (choice B) is not indicated in this case.
Naratriptan (choice C) is used for the acute treatment of migraine headaches. This is atypical for a migraine, but she should be further evaluated before she is discharged and treated.
Soft cervical collar and metaxalone (choice D) are used to treat headaches from cervical muscle spasms. There was no neck muscle spasms noted on exam, and she should be further evaluated before she is discharged.
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