A 35-year-old Caucasian man comes to the emergency department at 2 am because of severe
pain ‘behind the left eye’ which woke him up in the middle of the night The pain is intense and
has a stabbing quality He took ibuprofen at home but didn’t get any relief. He denies fever,
chills, decreased or blurred vision, cough, nausea or vomiting. He has no other medical
problems. He drinks 3-4 bottles of beer daily He has no known drug allergies. His temperature
is 36.r C (98° F), blood pressure is 120/80 mm Hg, pulse is 88/min and respirations are
14/min. The examination is unremarkable, except for left-sided ptosis and miosis. Which of the
following is the most likely diagnosis?
0 A Migraine headache without aura
0 B. Migraine headache with aura
0 C. Sinus headache
0 D. Trigeminal neuralgia
0 E. Brain tumor
0 F. Cluster headache
0 G. Tension headache
0 H. Subarachnoid hemorrhage
0 I. Meningitis
0 J. Orbital cellulitis
0 K. Angle closure glaucoma
0 L. Retinal detachment
0 M. Benign intracranial hypertension
D. Trigeminal neuralgia [6%)
E. Brain tumor [4%)
~ F. Cluster headache [58%)
G. Tension headache [1%)
H. Subarachnoid hemorrhage [4%)
I. Meningitis [0%)
J. Orbital cellulitis [3%]
K. Angle closure glaucoma [13%)
L. Retinal detachment [2%)
M. Benign intracranial hypertension [1%)
Explanation:
Cluster headache is characterized by intense unilateral retroorbital pain which starts suddenly
(usually at night), peaks rapidly, and lasts for approximately 2 hours. It is more common in men.
It may be accompanied by redness of the ipsilateral eye, tearing, stuffed or runny nose, and
ipsilateral Horner’s syndrome The attacks occur in clusters (suggested by the name), daily, for
six to eight weeks, followed by remission lasting for up to a year Since the attacks are short but
severe, prophylaxis is the key to management The recommended prophylactic medications
include verapamil, lithium and ergotamine The treatment for an acute attack is inhalation of
1 00% oxygen and subcutaneous sumatriptan.
Educational Objective:
Cluster headache usually presents with acute, severe retroorbital pain that wakes the patient from
sleep. It may be accompanied by redness of the ipsilateral eye, tearing, stuffed or runny nose,
and ipsilateral Horner’s syndrome