A 34-year-old man comes to the emergency department due to severe headache. The patient describes unbearable, throbbing pain around his right eye that awakened him. Over the past week, he has had several similar episodes, which spontaneously resolved after 20-30 minutes. He has no other medical conditions and takes no medications. The patient smokes a pack of cigarettes daily and drinks alcohol on social occasions. On physical examination, he appears restless and paces in the room. There is mild conjunctival injection and miosis of the right eye. Neurologic examination shows no abnormalities. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 34-year-old man comes to the emergency department due to severe headache.  The patient describes unbearable, throbbing pain around his right eye that awakened him.  Over the past week, he has had several similar episodes, which spontaneously resolved after 20-30 minutes.  He has no other medical conditions and takes no medications.  The patient smokes a pack of cigarettes daily and drinks alcohol on social occasions.  On physical examination, he appears restless and paces in the room.  There is mild conjunctival injection and miosis of the right eye.  Neurologic examination shows no abnormalities.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec160b_39b6_6a8f_9249_d9f582087d9e_MD0001_00 This young man with throbbing, unilateral periorbital headache associated with conjunctival injection and miosis has cluster headaches. The pathogenesis of cluster headaches is poorly understood but likely includes genetic predisposition, vascular dilation, and activation of the trigeminal-autonomic reflex. Males are affected more commonly than females. Cluster headaches present with rapid-onset, severe, unilateral periorbital and temporal pain; patients are often restless or agitated during episodes. Ipsilateral autonomic symptoms due to parasympathetic hyperactivity are common and include nasal congestion, lacrimation, ptosis, miosis, and conjuntival injection. The headaches typically last 15-180 minutes and tend to occur in clusters (often at the same time each day, even if asleep) over a period of several weeks. (Choice A) Cavernous sinus thrombosis typically occurs in patients with thrombophilia (eg, malignancy, antithrombin deficiency) or as a septic thrombosis related to a sinus infection or facial cellulitis. Orbital pain is common; however, it is typically worsened with eye movement. Periorbital swelling, fever, and proptosis are other frequent findings. (Choice C) Migraine without aura typically causes severe, pulsatile, unilateral headache often associated with photophobia, phonophobia, nausea, and vomiting. Miosis and lacrimation are unexpected. (Choice D) Opiate withdrawal can cause lacrimation, rhinorrhea, and diaphoresis, but would usually cause bilateral symptoms. It typically also causes gastrointestinal symptoms (eg, diarrhea, nausea), piloerection, and mydriasis; orbital pain is unexpected. (Choice E) Trigeminal neuralgia (tic douloureux) causes sudden, "electric" pain in the distribution of the maxillary and/or mandibular divisions of the trigeminal nerve, often preceded by light touch. Episodes last for seconds and do not typically occur during sleep. (Choice F) Vertebrobasilar ischemia can cause headaches but also typically causes dizziness, double vision or vision loss, and ataxia. Educational objective: Cluster headaches cause severe, episodic, unilateral periorbital and temporal pain associated with ipsilateral autonomic symptoms (eg, lacrimation, nasal congestion, miosis, conjunctival injection). The headaches typically last 15-180 minutes and tend to occur in clusters (often at the same time each day). Males are affected more commonly than females.

A 34-Year-Old Man Comes to the Emergency Department Due to Severe