A 29-year-old engineer comes to see you about his headaches. He has been getting a severe headache every night for the past three weeks. He says that the pain is "unbearable" and often wakes him from sleep.
He says that he wakes, often before midnight, with an intense pain around his right eye and that the pain radiates back to the whole head. It never seems to affect the left side of his head but he has noticed that he gets a runny nose during attacks. He says that he has had similar attacks a couple of times a year for the past few years but they usually subside after a couple of weeks.
He is a smoker and normotensive. Pupils are both equal and reactive. There is no abnormality testing cranial nerves and a quick neurological exam of the upper limbs is normal. His fundi appear normal but you note that he is extremely short sighted. There are no rashes visible.
After reading an article about migraine in a women's magazine he thought he should consult you about treatment.
What is the most likely diagnosis?
- Acute Herpes zoster infection
- Cluster headaches
- Chronic sinusitis
- Ramsay Hunt syndrome
- Space occupying lesion
- Temporomandibular joint dysfunction
Answer and explanation
Candidates have demonstrated poor performance in the clinical management of common causes of headache in previous exams, so it's reasonable to expect that you might be tested on this again.
This patient is describing cluster headaches. These headaches are commoner in men that women and tend to affect men from their late 20s onwards. Of all the causes of headaches, cluster headaches seem to result in the most severe discomfort and the pain is usually unilateral and located behind one eye.
They are termed cluster headaches because they tend to occur in clusters lasting several weeks, several times a year. Patients will often experience headaches within a few hours of falling asleep and they may have associated symptoms of rhinorrhoea. His myopia is a red herring and has no bearing on the diagnosis.
As we have stated in similar questions, the history is of much greater help in establishing a diagnosis for patients presenting with headache than the examination. The examination of patients presenting with headache serves mainly to assist in the reassurance of a worried patient, because it rarely adds to the diagnosis.
Patients with cluster headache may exhibit signs of rhinorrhoea, lacrimation or even ptosis if examined during an attack, but examination is usually normal when attending in surgery. However, it is wise, at the very least, to check the blood pressure and fundi of patients presenting with a headache. You should also consider palpating the head and neck for areas of tenderness.
This question also highlights another important issue - that patients sometimes reach their own conclusions about diagnoses and that these are not necessarily correct. Beware the patient attending for "antibiotics for my urine infection" or "tablets for my indigestion" without having ascertained the diagnosis for yourself!