A 27-year-old man comes to the emergency department with severe right eye pain. Over the last 3 days, he has had several episodes of "unbearable" eye pain that lasts 30-40 minutes and then resolves completely.
He would not sit down for a physical examination and paces around the room in pain. His right eye shows conjunctival injection with a constricted pupil. There is notable right-sided excessive lacrimation and rhinorrhea.
Which of the following is the best next step in managing this patient?

Question

A 27-year-old man comes to the emergency department with severe right eye pain.  Over the last 3 days, he has had several episodes of "unbearable" eye pain that lasts 30-40 minutes and then resolves completely.
He would not sit down for a physical examination and paces around the room in pain.  His right eye shows conjunctival injection with a constricted pupil.  There is notable right-sided excessive lacrimation and rhinorrhea.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_965d_5825_853d_b9cef2c02fd1_MD0002_00 This patient's presentation is consistent with cluster headache (Table). Cluster headache is more common in men, and the diagnosis is suggested when the patient has 5 or more severe headache attacks with 1 or more ipsilateral autonomic symptoms (eg, ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestion). Patients are usually agitated or restless, which can help differentiate cluster headache from migraine. Brain MRI, even in the setting of a typical presentation, is usually obtained during the initial evaluation to exclude intracranial abnormalities. Current guidelines recommend 100% oxygen (12 L/min for 15 min) and/or subcutaneous sumatriptan as a first-line treatment for acute cluster headache. Preventive therapy should also be promptly initiated. Verapamil is the preferred preventive treatment, sometimes accompanied by a short course of oral corticosteroids. (Choices A and E) Acute angle-closure glaucoma (ACG) may present with severe headache, eye pain, and conjunctival injection; however, this patient's young age and absence of other features (eg, decreased vision, nausea/vomiting, poorly reactive mid-dilated pupil) make the diagnosis unlikely. ACG warrants emergent referral to an ophthalmologist. Patients who cannot be seen by a specialist within an hour may be empirically treated with topical pilocarpine and other intraocular pressure-lowering agents (eg, timolol, apraclonidine). Acute angle-closure glaucoma (ACG) (Choice B) There is no compelling evidence that opiates, such as intravenous morphine, are effective for cluster headache. (Choice D) Topical corticosteroids are usually indicated for noninfectious anterior uveitis (iritis). Anterior uveitis can present with eye pain, conjunctivitis, and a miotic pupil; however, it is often associated with loss of vision and would not explain this patient's ipsilateral lacrimation and rhinorrhea. Anterior uveitis Educational objective: Cluster headache typically presents with multiple short attacks of severe unilateral periorbital, supraorbital, or temporal pain associated with restlessness and ipsilateral autonomic symptoms (eg, ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea/nasal congestion). Acute therapy usually involves oxygen and/or sumatriptan. Verapamil is the preferred agent for chronic preventive therapy. __________ References: Acute and preventive pharmacologic treatment of cluster headache. (http://www.ncbi.nlm.nih.gov/pubmed/20679639) Acute and preventive treatment of cluster headache and other trigeminal autonomic cephalgias. (http://www.ncbi.nlm.nih.gov/pubmed/20816442)

A 27-Year-Old Man Comes to the Emergency Department with Severe