A 22-year-old woman comes to the emergency department due to a severe left frontal headache for the past 30 minutes. The patient has had similar pain every day for the past 3 days, and the episodes resolve spontaneously after about an hour. She has no other medical conditions and takes no medications. On physical examination, the patient appears restless and in pain. There is ptosis on the left side. Which of the following findings is most suggestive of cluster headache in this patient?

Question

A 22-year-old woman comes to the emergency department due to a severe left frontal headache for the past 30 minutes.  The patient has had similar pain every day for the past 3 days, and the episodes resolve spontaneously after about an hour.  She has no other medical conditions and takes no medications.  On physical examination, the patient appears restless and in pain.  There is ptosis on the left side.  Which of the following findings is most suggestive of cluster headache in this patient?

Quizplus · Accepted Answer

11ec160b_39b7_06d0_9249_2fcf6702b846_MD0001_00 This patient with recurrent, unilateral, severe headaches accompanied by ptosis has cluster headache, a type of trigeminal autonomic cephalalgia. Cluster headaches often present with rapid-onset, severe, unilateral pain that is typically periorbital, frontal, or temporal. Patients are often restless or agitated during episodes. Cluster headaches are often accompanied by ipsilateral autonomic symptoms, which may include: Headaches typically last 15-180 minutes and tend to occur in clusters (up to 8 times daily, often at the same time of day) over a period of several weeks. In some patients, clusters occur at similar seasons of the year. This clustering may suggest involvement of the hypothalamus, which regulates circadian rhythms. Treatment of acute headaches is often with oxygen or triptans (eg, sumatriptan); verapamil is frequently used for preventive treatment. (Choice A) Both migraines and cluster headaches tend to have discrete episodes, so episodic nature is not a distinguishing feature in itself. The timing of the episodes (eg, around the same time every day, several days in a row) and the duration (eg, 15-180 min) are more characteristic of cluster headache, but the most obvious differentiating feature is the presence of autonomic symptoms. (Choice B) Cluster headaches can occur in anyone, but they are more common in male patients. (Choice C) Although cluster headaches are located in the frontal region, other types of headaches can also be frontal in location (eg, sinusitis, migraine), so this is not a specific differentiating feature. (Choice E) Although cluster headaches are typically unilateral, migraine headaches are also often unilateral, so this is not helpful in distinguishing between those. Educational objective: Cluster headaches often present with rapid-onset, severe, unilateral pain accompanied by ipsilateral autonomic symptoms (eg, ptosis, miosis, nasal congestion, conjunctival injection).

A 22-Year-Old Woman Comes to the Emergency Department Due to a Severe