“Disclaimer: This clinical scenario is for educational purposes only and by no means serves as a guideline for diagnosis and treatment. If you feel you have similar symptoms and signs, I recommend you see your personal physician for advise.”
David is an accountant with a busy schedule from Manhattan, New York. The otherwise healthy 30-year-old male just had one of the most painful experiences of his time in the office while attending to the client. Since it was his second time experiencing such an unfortunate event, David decided to present himself to the Urgent Care located a couple of blocks from his job.
Upon arrival at Urgent Care, David seemed to be in significant distress, agitated, and restless. The Doctor sees David holding his head with his hands and violently walking around the exam room.
Hi David! My name is Dr. Smith; I am an internist on the call today! I am sorry to see you are in lots of pain!
Hello Doctor! David responds in anguish! Yes! It is the worst pain I have ever experienced; David continues.
Doctor Jones: Can you describe the pain and how it started? What may have initiated this?!
David: This is the second time I have had this kind of headache. The previous episode was two months ago when it woke me up in the middle of the night.
Both times, the pain hit my left temple like someone was stabbing the back of my eyeball multiple times; David continues!
David’s left eye looks red as he snuffles constantly!
While rubbing his left temple with his left hand and holding his eye on the same side with his Right hand, David speaks with a groaning voice. Last time my headache lasted about 30 minutes, doc! — But it suddenly faded away.
Nothing seems to make it better! — Even Acetaminophen and Ibuprofen fail to do any good.
Last time I had to tough it out, but I am worried now. It may be something serious.
Dr. Jones approaches David with an empathic countenance, gently grabs David’s hand, and voices! — I will check your vital signs and do a quick exam, David!
Then, Doctor continues with a physical exam for the next 10 minutes.
Doctor Jones’ positive finding from examination includes a distressed demeanor, Left eye redness, and congested nose inner lining, mainly on the side of the headache.
Your headache will likely subside in the next hour or so. Nevertheless, I can give you an injection or 100% oxygen through a facemask to help you feel better, Dr. Jones explains to David!
Then Doctor adds, It is hard to tell when your next episode will be again; however, if it happens too often, we may have to start you on a long-term treatment plan.
What kind of injection? Dr, David replies!
The medication is called Dihydroergotamine, Dr. Jones replies! But why not try the Oxygen therapy first?!
Cluster headaches are among the most excruciatingly painful experiences. David’s case represents the classic example of a typical scenario of Cluster Headache. Its diagnosis is usually based on clinical presentation, as we witness in David’s case. However, sometimes it needs to be differentiated from other forms of headaches.
SUNCT (or Short lasting unilateral neuralgiform headache with conjunctival injection and tearing) can often be hard to differentiate from Cluster headaches. However, painful clusters of attacks with SUNCT are often briefer and happen in high frequency. That is in contrast to the Cluster Headaches of David, for whom the episodes are less frequent and last longer, over 30 minutes.
Chronic Paroxysmal Hemicrania (CPH) also happens more frequently and is much briefer. Nevertheless, Unlike SUNCT and Cluster Headaches, CPH typically responds only to Nonsteroidal Anti-Inflammatory medications (NSAIDs), Indomethacin, not other NSAIDs.
David was given Oxygen of 100% concentration via a facemask for ten minutes. His symptoms improved. Preventative treatment was deferred for the time being, as the episodes don’t seem to happen frequently.
The Doctor, however, prescribes David a Zolmitriptan Nasal spray if he encounters another episode in the future.
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