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Review Question - QID 106533

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QID 106533 (Type "106533" in App Search)
A 25-year-old man presents to the emergency department for evaluation of headache. He states that his headache started 20 minutes prior to arrival. He states that the pain is located around his right eye. He denies fever, visual changes, or any other associated symptoms. He states that he has had several of these headaches over the past several weeks. He has no significant medical history, and smokes one pack of cigarettes most days. His temperature is 98.6°F (37.0°C), pulse is 90, blood pressure is 130/80 mmHg, respirations are 16/min, and pulse oximetry is 99% on room air. On exam, there are no focal neurologic deficits. Lacrimation is noted in the right eye. There is clear rhinorrhea noted. Which of the following is the most likely diagnosis?

Acute angle-closure glaucoma



Cluster headache



Migraine headache



Tension type headache



Trigeminal neuralgia



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This patient with a periorbital headache, lacrimation, rhinorrhea and history of smoking likely has a cluster headache.

Cluster headaches characteristically present with unilateral periorbital pain, and last for 30 minutes to several hours. Pain is often reported to be quite severe. Cluster headache is always accompanied by at least one autonomic symptom, such as lacrimation or rhinorrhea as in this patient. Facial diaphoresis, ptosis, or miosis may also be observed. Often, cluster headaches present in a seasonal pattern, with multiple headaches occurring in the span of several weeks, followed by a headache-free period up to a year in length. While the pathophysiology of cluster headache is not well understood, the diagnosis can be made clinically without any additional laboratory testing or imaging necessary. Treatment of acute cluster headache includes the use of supplemental oxygen and triptan medications. For those with frequent headaches, calcium channel blocking medications are often used for prophylaxis.

Weaver-Agostoni review the diagnostic criteria of CH. Patients must have a severe unilateral headache in the frontal or periorbital area. It must last between 15-180 minutes (if left untreated), and they may occur from once every other day up to 8 times per day. Associated symptoms must be present and include: conjunctival injection, lacrimation, rhinorrhea, eyelid edema, miosis, or ptosis. CH typically occur at the same time every day. The severity of the CH is usually decreased by activity.

Nesbitt et al. briefly discuss the etiology of CHs. CHs are in the class of trigeminal autonomic cephalalgias (TACs). TACs include CH, CPH, hemicrania continua, and SUNCT syndrome. These syndromes typically have unilateral pain of high severity and with frequent recurrence. Autonomic symptoms are also common. Activation of the trigeminovascular reflex through the trigeminocervical complex is regulated by the posterior hypothalamus. Dysregulation of this pathway is thought to mediate both the pain and autonomic symptoms of TACs.

Incorrect Answers:
Answer 1: Acute-angle closure glaucoma often presents with eye pain or a periorbital headache. However, changes in visual acuity would be expected, along with a fixed, mid-dilated pupil on exam. This patient's presentation more strongly suggests cluster headache as the diagnosis.

Answer 3: Migraine headache often presents as a unilateral headache, with associated photophobia, nausea, and vomiting being common. While autonomic symptoms such as this patient's rhinorrhea and lacrimation may also be observed in patients with migraine headache, this patient's presentation more strongly suggests cluster headache as the diagnosis.

Answer 4: Tension type headache characteristically presents with pain in a "band-like" distribution across the head. Periorbital pain, along with rhinorrhea and lacrimation would not be expected and is more suggestive of a cluster headache.

Answer 5: Trigeminal neuralgia presents with pain in the distribution of the trigeminal nerve branches. While periorbital pain may be observed, trigeminal neuralgia typically causes pain lasting only several seconds.

Bullet Summary:
Cluster headache is characterized by periorbital pain occurring in a seasonal pattern with associated autonomic symptoms such as lacrimation or rhinorrhea.

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