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Man With Multiple Short-Lasting, Unilateral Daily Headaches

Man With Multiple Short-Lasting, Unilateral Daily Headaches

The patient is a 56-year-old man who presents with daily headaches that occur behind the right eye, right temple, and occasionally on the right side of the forehead. He has never experienced this type of headache on the left side. He describes the pain as “stabbing,” “throbbing,” and occasionally “burning.” He rates the intensity of the pain a 7 on a 10-point visual analog scale on which 10 is the most severe.

The acute headaches last between 20 and 40 seconds; the severe component of each episode lasts for about 3 seconds. The patient reports that on some days he suffers from 12 to 100 acute episodes per day (usually about 40 to 60). Occasionally, his headaches resolve for a few days or a week without special treatment, but they eventually recur.

The patient also reports conjunctival injection and lacrimation of the right eye during each headache attack. He sometimes experiences congestion of the right nostril during an attack but denies any associated nausea or vomiting. He has tried different abortive medications (including triptans, indomethacin, and over-the-counter analgesics) without success.

This patient’s headaches started 2 years ago without any precipitating factors. Since then, they have become more frequent, but the clinical features are unchanged.

MRI and magnetic resonance angiography (MRA) scans of the brain are normal.

1 What types of headache present as multiple daily short-lasting attacks with unilateral pain?

2 What specific clinical features of the headache are key to the diagnosis?

3 What is the diagnosis in this patient—and why do primary care clinicians need to know about it?

(Answers on next page.)


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