A 36-year-old man presents to the emergency department with a severe headache. He reports that two hours ago he began experiencing severe pain over his left forehead and around his left eye. He also reports a moderate amount of nasal discharge. The patient has had multiple similar hour-long episodes of left-sided headaches for the past 2 days. Past medical history is otherwise unremarkable, and he does not take any medications. He drinks one glass of wine on the weekends and does not use tobacco or any recreational drugs. Vital signs are temperature 36.7°C (98.1°F), blood pressure 129/76 mmHg, pulse 122 beats/min, and respirations 16/min. On physical examination, the patient appears uncomfortable, rocking back and forth in his chair and rubbing his forehead. There is conjunctival injection and mild ptosis of the left eye. The left pupil is smaller than the right and both pupils constrict equally to light. There is moderate watery nasal discharge. Examination of the cranial nerves is normal. Bilateral biceps and patellar reflexes are 2+. Strength and sensation are normal in all extremities.
Which of the following is the most appropriate treatment for acute control of the patient’s symptoms?
A) 100% oxygen
This patient has findings consistent with a diagnosis of cluster headache (CH). CH is a type of primary headache (a headache not caused by an underlying disease) that is more common in men. CH presents as attacks of unilateral excruciating periorbital pain that last from fifteen minutes to three hours and is usually associated with ipsilateral autonomic symptoms such as conjunctival injection, lacrimation, rhinorrhea as well as with and partial Horner syndrome (ptosis and miosis without anhidrosis). CH tends to occur in episodes (“cluster periods”) which are often followed by months of remission. The diagnosis of CH is clinical. Only patients with red-flag symptoms of headache such as systemic symptoms, abnormal neurologic exam, signs of raised intracranial tension, or posttraumatic onset require an MRI to rule out secondary headache. Acute treatment of CH is with 100% oxygen therapy. Other first-line treatment options include subcutaneous sumatriptan or zolmitriptan nasal spray. For long-term prophylaxis, verapamil is the first-line treatment option while lithium and topiramate are other options.
Answer choice B: Carbamazepine, is incorrect. Carbamazepine, an antiepileptic sodium channel blocker, is the first-line treatment for trigeminal neuralgia. Trigeminal neuralgia presents as unilateral shooting pain in the distribution of the trigeminal nerve that characteristically intensifies with chewing, talking, or touching various areas of the face. Episodes usually last for seconds to minutes and may progressively increase in intensity and frequency. Carbamazepine is also used in the treatment of focal seizures, generalized tonic-clonic seizures, and bipolar disorder.
Answer choice C: Gabapentin, is incorrect. Gabapentin, an antiepileptic calcium-channel blocker is primarily used for the treatment of peripheral neuropathy, neuropathic pain, and postherpetic neuralgia.It also has other off-label uses such as the treatment of alcohol withdrawal symptoms.
Answer choice D: Ibuprofen, is incorrect. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that exerts its analgesic, antipyretic, and anti-inflammatory effects by reversible inhibition of the cyclooxygenase (COX) enzymes. It is indicated for the symptomatic control of pain and fever in a variety of conditions. NSAIDs are a first-line treatment option for both migraine and tension headaches but are ineffective for cluster headaches. Migraine headache is a type of primary headache characterized by unilateral pulsating/throbbing pain with photophobia, phonophobia, or aura (transient flashing lights, sounds, vision loss, hearing loss, sensory disturbances, or motor dysfunction). Children with migraine headaches may exhibit atypical symptoms such as bilateral headache and concurrent autonomic symptoms. NSAIDs, triptans, dihydroergotamine, and anti-emetics (metoclopramide, promethazine) are used in the acute treatment of migraine. For long-term prophylaxis, treatment options include lifestyle changes (sleep, exercise, diet), antidepressants (amitriptyline, imipramine), antiepileptics (valproate, topiramate), beta-blockers (propranolol), botulinum toxin, calcium-channel blockers (verapamil), and calcitonin gene-related peptide antagonists. Tension headache is another type of primary headache and is characterized by constant, steady, bilateral band-like pain across the forehead without any photophobia, phonophobia, or aura. Acute treatment is with NSAIDs, and options for long-term prophylaxis include tricyclic antidepressants (e.g., amitriptyline) and behavioral therapy.
Answer choice E: Verapamil, is incorrect. Verapamil is a calcium-channel blocker and is indicated for long-term prophylaxis of cluster headaches, but it is not effective for acute control of symptoms. Other indications of verapamil include hypertension, angina pectoris, hypertrophic obstructive cardiomyopathy, and cardiac arrhythmias.
Key Learning Point
Subtypes of primary headache include cluster, migraine, and tension headache. Cluster headache presents as episodic unilateral excruciating periorbital pain associated with ipsilateral autonomic symptoms (conjunctival injection, lacrimation, rhinorrhea) and partial Horner syndrome (ptosis and miosis without anhidrosis). Acute treatment is with 100% oxygen or triptans. Verapamil is the first-line treatment option for long-term prophylaxis.
