A 28-year-old man comes to the office for a health maintenance visit. He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen. Occasionally the headaches are severe enough to necessitate taking a sick day from work. He cannot recall specific triggers but notes that the headaches are usually unilateral. The patient does not use tobacco or illicit drugs. He drinks alcohol socially and 2-3 cups of coffee daily. He is a software engineer and often works at a computer 10-12 hours a day. His sister has a history of migraines. Vital signs are within normal limits. Physical examination, including neurological examination, is normal. The patient returns to the office 2 weeks later and reports "on and off" headaches almost every day since his last visit. The headaches are predominantly behind his left eye and are so severe that his left eye becomes watery and his forehead feels sweaty. The headaches occur at approximately the same time each day and improve after resting in a dark, quiet room for about an hour. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Question

A 28-year-old man comes to the office for a health maintenance visit.  He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen.  Occasionally the headaches are severe enough to necessitate taking a sick day from work.  He cannot recall specific triggers but notes that the headaches are usually unilateral.  The patient does not use tobacco or illicit drugs.  He drinks alcohol socially and 2-3 cups of coffee daily.  He is a software engineer and often works at a computer 10-12 hours a day.  His sister has a history of migraines.  Vital signs are within normal limits.  Physical examination, including neurological examination, is normal. The patient returns to the office 2 weeks later and reports "on and off" headaches almost every day since his last visit.  The headaches are predominantly behind his left eye and are so severe that his left eye becomes watery and his forehead feels sweaty.  The headaches occur at approximately the same time each day and improve after resting in a dark, quiet room for about an hour.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: This patient has unilateral, orbital headaches of short duration associated with autonomic symptoms, suggesting cluster headache. Cluster headaches primarily affect men and are characterized by headaches that last <180 minutes and occur 1-8 times a day over a period of weeks. The headaches are orbital, supraorbital, or temporal and always unilateral. The pain during a cluster headache can be so severe as to lead to suicide. Patients also usually experience restless agitation (unable to sit still) and ipsilateral autonomic symptoms such as ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion. (Choice A) Generalized anxiety disorder can be associated with tension-type headaches and generalized autonomic hyperactivity (eg, palpitations, sweating). Focal autonomic hyperactivity in the trigeminal branch associated with unilateral orbital headache is much more likely to indicate cluster headache. (Choice C) Migraine headaches can cause unilateral orbital headaches that improve with resting in a dark, quiet room (to reduce phonophobia and photophobia). However, migraines are typically not associated with trigeminal autonomic hyperactivity. (Choice D) Temporal arteritis is a vasculitis often associated with unilateral headache, vision change, and jaw claudication. Temporal arteritis almost always affects patients age >50; this young patient is unlikely to have temporal arteritis. (Choice E) Tension-type headaches are usually bilateral, band-like, and nonthrobbing. This patient with episodic, unilateral, orbital headaches associated with autonomic symptoms is more likely to have cluster headache. Educational objective: Cluster headaches are primarily seen in men and are characterized by episodic headaches 1-8 times a day occurring over a period of weeks. The pain is typically orbital, supraorbital, or temporal as well as unilateral and severe. Patients usually have restless agitation and autonomic symptoms of the ipsilateral trigeminal branch such as lacrimation, conjunctival injection, rhinorrhea, and nasal congestion.

A 28-Year-Old Man Comes to the Office for a Health