A 34-year-old man comes to the emergency department at 2:00 AM due to several episodes of acute right periorbital pain for the past week. The pain wakes him at night, spreading from behind his right eye to his face and right temple, and lasts 30-45 minutes. He says that the pain is so severe that his right eye waters and he has nasal drainage. The patient has no nausea or visual disturbances. Two years ago, he had similar episodes daily for about a month. Temperature is 37 C (98.6 F), blood pressure is 136/84 mm Hg, and pulse is 88/min. The patient is restless and continuously rocks back and forth or paces around the room. Physical examination shows conjunctival injection and a constricted right pupil. Other examination findings, including neurologic examination, are normal. Which of the following is most likely to quickly improve this patient's current condition?

Question

A 34-year-old man comes to the emergency department at 2:00 AM due to several episodes of acute right periorbital pain for the past week.  The pain wakes him at night, spreading from behind his right eye to his face and right temple, and lasts 30-45 minutes.  He says that the pain is so severe that his right eye waters and he has nasal drainage.  The patient has no nausea or visual disturbances.  Two years ago, he had similar episodes daily for about a month.  Temperature is 37 C (98.6 F), blood pressure is 136/84 mm Hg, and pulse is 88/min.  The patient is restless and continuously rocks back and forth or paces around the room.  Physical examination shows conjunctival injection and a constricted right pupil.  Other examination findings, including neurologic examination, are normal.  Which of the following is most likely to quickly improve this patient's current condition?

Quizplus · Accepted Answer

This patient, who has recurrent episodes of acute, severe right periorbital pain accompanied by autonomic manifestations (eg, ipsilateral miosis, lacrimation) but no vision changes, most likely has cluster headaches. Of all regimens available, 100% oxygen by facemask is the most rapid-acting and effective in aborting a cluster headache attack without any major side effects. Subcutaneous sumatriptan can also be used, as long as there are no contraindications (eg, ischemic cardiac disease, pregnancy). The paroxysms of cluster headache attacks begin during sleep, peak rapidly, last approximately 90 minutes, and occur up to 8 times daily for 6-8 weeks, followed by a period of remission. As the attacks are short but severe, prophylactic medication (eg, verapamil, lithium) is the key to management and should be started as soon as possible after the onset of an acute attack (Choice I). (Choice A) Acetazolamide is a diuretic used to treat pseudotumor cerebri, which is generally seen in obese women with headaches and visual changes (not seen in cluster headaches). (Choice B) Carbamazepine is used to treat trigeminal neuralgia, a disorder characterized by recurrent and sudden-onset, severe, stabbing pain along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve, but is not associated with miosis. trigeminal nerve (Choice C) Ergotamine may be used to abort an acute cluster headache attack, especially when started early, but 100% oxygen is the most rapid-acting and effective treatment without side effects. Dihydroergotamine is used for acute treatment of migraine headaches, which are typically pulsatile and accompanied by nausea, vomiting, or photophobia. (Choice D) Glucocorticoids are indicated in patients with temporal arteritis (age >50, headache with localized temporal tenderness, elevated erythrocyte sedimentation rate). Although glucocorticoids are sometimes prescribed temporarily for prophylaxis of cluster headaches, their side-effect profile (eg, hyperglycemia, osteoporosis) limits their long-term use. (Choices F and H) Nonsteroidal anti-inflammatory drugs (eg, indomethacin) are used for acute management of tension headaches (usually bilateral and not accompanied by lacrimation, conjunctival injection, or miosis) and some cases of migraine headaches. Topiramate is an anticonvulsant used for prophylaxis of migraine headaches. These medications are rarely used for prophylaxis of cluster headaches. (Choice G) Orbital massage can be useful in central retinal artery occlusion (unilateral acute painless vision loss), as a way to remove an embolism by increasing outflow of aqueous humor as well as perfusion to the eye; it is unlikely to be effective in cluster headaches. Educational objective: Providing 100% oxygen by facemask is an effective and rapid method used to abort an acute cluster headache without major side effects. References: Cluster headache. (http://www.ncbi.nlm.nih.gov/pubmed/22496300)

A 34-Year-Old Man Comes to the Emergency Department at 2:00