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 comes to the emergency department at 1 AM later that night due to unrelenting headache. He was awakened 2 hours prior by severe, sharp, periorbital pain on the left side of his head. He also has had nausea and watering from the left eye. The patient took ibuprofen and acetaminophen but experienced no relief. Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 92/min, and respirations are 16/min. Pulse oximetry shows 98% while breathing ambient air. He appears in pain and is restless. Physical examination shows mild ptosis and miosis of the left eye. There is clear discharge from the left nostril. He has no other focal neurological deficits, and the remainder of the physical examination is normal. Which of the following is the most appropriate intervention at this time?

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 comes to the emergency department at 1 AM later that night due to unrelenting headache.  He was awakened 2 hours prior by severe, sharp, periorbital pain on the left side of his head.  He also has had nausea and watering from the left eye.  The patient took ibuprofen and acetaminophen but experienced no relief.  Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 92/min, and respirations are 16/min.  Pulse oximetry shows 98% while breathing ambient air.  He appears in pain and is restless.  Physical examination shows mild ptosis and miosis of the left eye.  There is clear discharge from the left nostril.  He has no other focal neurological deficits, and the remainder of the physical examination is normal.  Which of the following is the most appropriate intervention at this time?

Quizplus · Accepted Answer

Explanation: This patient comes to the hospital due to severe, acute pain from an ongoing cluster headache. First-line therapy for acute management of cluster headache is 100% oxygen inhalation by nonrebreathing facial mask. This treatment is administered for >15 minutes and provides significant relief in >70% of patients. Patients with partial or no response to oxygen therapy are often given intranasal sumatriptan contralateral to the side of headache. This therapy is considered second-line due to the risk of adverse effects and medication-overuse headaches. Intranasal lidocaine and ergot preparations are also sometimes used. (Choices A and B) Glucocorticoids and verapamil are often used in the preventive treatment of cluster headaches; they are not used for aborting acute headaches. (Choice C) There are no current manifestations (eg, fever, nuchal rigidity) of a central nervous system infectious process; lumbar puncture would not be indicated. This patient with a severe, periorbital, unilateral headache associated with restlessness and autonomic symptoms is likely to have a cluster headache. (Choice D) Subarachnoid hemorrhage is often diagnosed by noncontrast CT scan of the head. Manifestations typically include a sudden, severe headache. However, ipsilateral autonomic signs would be atypical. Educational objective: First-line therapy for acute management of cluster headache is 100% oxygen inhalation. This treatment improves or aborts headaches in >70% of patients.

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