Clinical Case 105: Headache Take 5

Ok Neuro nerds…  here’s a quick case to test your diagnostic skills.  It is one of those common scenarios we see.

35 year old man presents for the 5th day in a row complaining of the same headache he came in with on the 1st day!

He is usually fit and well, but has been prone to headaches over the years – never really diagnosed.

He describes the headache as being very similar each day, starting at various times during the day.  He get sharp, boring intense pain around his right eye which throbs into his temple.  He describes spasm of pain which last for 10 – 20 minutes and then fade to a dull ache.  He has noticed his right eye waters a lot during the attacks and nothing seems to help.  The pin is disabling in intensity and he needs to stop doing whatever he is doing and go sit / lay down until it passes.  In between attacks he is pain free but is starting to feel apprehensive – as he knows it is coming back!

There is accompanying nausea but no vomiting.  No real photophoia or odynophobia.  He cannot recall any aura or visual symptoms prior to these headaches.

He has been under some stress lately at work and this week his boss has had a go at him for “slacking off” and suspects these headaches are artifactual! There has been tension about money in the business for weeks.

Looking back through the chart of the past 4 visits – he has had a range of treatments – paracetamol, hot compresses, IM ketroloac, aspirin, caffeine, oral tramadol and oxygen therapy.

Nobody has been able to document any focal neurological signs of neck stiffness. He has had no syncope or trauma.

Ah 0 easy you think!  Classical cluster headache – we can fix this with high flow oxygen pronto!

As you make a move to place a Hudson mask over his face he slaps it away….

“Everyone has tried that all week!  It hasn’t helped.  It just annoys me and I feel claustrophobic with that mask on.!!”

Hmmm…. maybe not so typical.

So what is going on?

Q1: What is the probable diagnosis?

Q2:  What is the treatment of choice?

Q3: Will you get any neuro imaging?  This is day 5!  Is this something nasty?


  1. David Berger says

    1. Episodic paroxysmal hemicrania.
    2. Indomethacin.
    3. CT brain because everyone gets a CT brain.

    • BINGO! Good call mate.
      This is one of those great diagnoses to make in primary care – fixable and easy enough to treat.

      If the Indomethacin works well – then I would hold off on the CT
      It is basically a “diagnostic intervention” in this disease. At best the CT will be normal. Thought he pretest probability of anything on CT is pretty low on that history I would think?

  2. Could still be cluster headache – oxygen doesn’t work for everyone. I would try a triptan.

    Other consideration is trigeminal neuralgia. Less common though generally, and especially in this demographic.


  3. I would have thought that the variability in time of onset would suggest that this isn’t cluster, despite the lacrimation?

  4. A firm diagnosis is not really possible given that the pattern of the headache syndrome cannot be established after only 5 days.

    It should be noted that cluster headaches are relatively common – at least an order of magnitude more frequently than episodic paroxysmal hemicrania. Only about 2/3 of cluster headaches respond to O2. Described timings are important but I’d like to know the likelihood ratios of these – I suspect that they aren’t stellar.

    Exquisite sensitivity to indomethacin is a defining feature of paroxysmal hemicrania that differentiates it from the other headache syndromes and I suppose that you won’t know until you try. I would have thought that poor response to ketoralac would have reduced the probability of this diagnosis.


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