Case history
Case history
A 44-year-old male smoker presents with a 9-year history of recurrent headache attacks. Headache attacks occurred twice-monthly initially, always in the early hours of the morning (2 a.m. to 3 a.m.). The headache attacks have increased to an average of two per day. The acute attacks can occur at any time, and last between 2 and 4 hours. He always has a nocturnal attack. Attacks are triggered immediately after drinking alcohol or with the smell of strong aftershave or gasoline. The pain is excruciating and focused around his right eye. The right eye reddens and tears, the right eyelid droops, and the right nostril runs. He becomes severely agitated during attacks, often pacing the room or rocking back and forth. Physical exams, lumbar puncture, brain magnetic resonance imaging (including pituitary views), and pituitary function blood tests are normal.
Other presentations
Migraine-associated features can be seen in cluster headache, including aura symptoms (reported in 23.0% of patients in one study), ipsilateral photophobia and/or phonophobia (61.2%), and nausea and vomiting (27.8%).[3] During remission periods, patients may report mild "shadows" of pain in the same location as the cluster headache attacks. A small percentage of patients do not report autonomic features or agitation during attacks. Continuous background pain has been reported in nearly one third of patients with chronic cluster headache.[4]
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