A 35-year-old man comes to the emergency department due to severe pain behind his left eye. The patient reports that the pain is intense and stabbing and that it woke him up around midnight. It improved after 30 minutes and he was about to go back to sleep when the same pain began again. He took ibuprofen without relief. Several months ago, the patient had similar episodes of pain that resolved spontaneously after 2 weeks. He has had no fevers, blurry vision, nausea, or vomiting but has had nasal congestion. The patient has seasonal allergies for which he takes cetirizine. He works as a flight operations officer and describes his job as "pretty stressful." He drinks 2 or 3 cups of coffee daily and drinks alcohol occasionally. His mother has migraine headaches. Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, and pulse is 94/min. The patient is restless and agitated. Physical examination shows left-sided ptosis, miosis, and rhinorrhea. Neurologic examination shows bilateral equal and normal motor strength, sensation, and deep tendon reflexes. Which of the following is the most likely cause of this patient's headache?

Question

A 35-year-old man comes to the emergency department due to severe pain behind his left eye.  The patient reports that the pain is intense and stabbing and that it woke him up around midnight.  It improved after 30 minutes and he was about to go back to sleep when the same pain began again.  He took ibuprofen without relief.  Several months ago, the patient had similar episodes of pain that resolved spontaneously after 2 weeks.  He has had no fevers, blurry vision, nausea, or vomiting but has had nasal congestion.  The patient has seasonal allergies for which he takes cetirizine.  He works as a flight operations officer and describes his job as "pretty stressful."  He drinks 2 or 3 cups of coffee daily and drinks alcohol occasionally.  His mother has migraine headaches.  Temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, and pulse is 94/min.  The patient is restless and agitated.  Physical examination shows left-sided ptosis, miosis, and rhinorrhea.  Neurologic examination shows bilateral equal and normal motor strength, sensation, and deep tendon reflexes.  Which of the following is the most likely cause of this patient's headache?

Quizplus · Accepted Answer

11ec25c8_d549_998e_bc81_81e6bb7c457f_MD0003_00 This patient with episodes of acute left retro-orbital pain accompanied by ipsilateral autonomic manifestations (eg, ptosis, miosis, rhinorrhea) likely has cluster headaches. These headaches are generally seen in young men, are unilateral, and can be accompanied by redness of the ipsilateral eye with tearing but no visual changes, as well as by agitation due to the severity of the pain. The autonomic manifestations may be similar to those seen with Horner syndrome (ptosis, miosis, anhidrosis). 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 remission lasting up to a year. Because the attacks are short but severe, prophylactic medication (eg, verapamil, lithium) is important for management. An acute attack can be aborted with inhalation of 100% oxygen or with subcutaneous sumatriptan. (Choices A and G) Acute maxillary sinusitis can present with facial pain and rhinorrhea, but there is usually associated fever and anosmia. Orbital cellulitis is an infection of the fat and extraocular muscles of the eye. Patients usually have erythema, edema, and tenderness, often with impaired extraocular movement. These conditions generally do not cause paroxysms of severe retro-orbital pain or miosis. Orbital cellulitis (Choice B) Angle closure glaucoma usually presents with sudden-onset eye pain, nausea, and diminished vision with halos seen around lights. Patients typically have a fixed and mid-dilated pupil and not ptosis or miosis. Angle closure glaucoma (Choices C, E, and I) A brain tumor typically presents with progressive headache, morning nausea, and focal neurologic deficits due to mass effect. A lacunar infarction can have a range of syndromic presentations (eg, pure motor hemiparesis, ataxic-hemiparesis, dysarthria/clumsy hand). A subarachnoid hemorrhage is characterized by sudden-onset, persistent, severe headache that can be associated with vomiting, seizure, and a decreased level of consciousness. None of these conditions would cause recurrent severe retro-orbital pain in a young patient. (Choices F, K, and L) Migraines are usually associated with nausea, vomiting, and photophobia; these headaches are typically pulsatile and throbbing rather than sharp and severe. Tension-type headaches can occur due to stress but are usually non-throbbing and bilateral. Trigeminal neuralgia is characterized by recurrent and sudden-onset stabbing pain along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve. The episodes last a few seconds to minutes and can be triggered by minor stimuli (eg, wind). Ptosis, miosis, and rhinorrhea are more suggestive of cluster headache. trigeminal nerve (Choice H) A retinal detachment typically presents with light flashes, floaters, or a curtain across the visual field that usually starts from the periphery and is generally not painful. retinal detachment floaters curtain (Choice J) Substance use disorder can present with agitation and restlessness, but it does not usually present with unilateral ptosis and miosis or with sudden-onset and recurrent retro-orbital eye pain. Educational objective: Cluster headaches usually present with acute, unilateral, severe retro-orbital pain that awakens patients from sleep. These headaches may be accompanied by redness and tearing, rhinorrhea, and ipsilateral ptosis and miosis. References: Cluster headache. (http://www.ncbi.nlm.nih.gov/pubmed/22496300) The international classification of headache disorders, 3rd edition (beta version). (http://www.ncbi.nlm.nih.gov/pubmed/23771276)

A 35-Year-Old Man Comes to the Emergency Department Due to Severe