Headache Quiz: Test Your Diagnostic Skills

Case 1

A 30-year-old man describes severe unilateral temporal pain accompanied by nasal congestion and tearing. These attacks have occurred before and are normally 45 to 60 minutes in duration. He has experienced these symptoms every other day for the past few weeks. They usually last a few weeks, then go away and come back again. What's your diagnosis?

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Answer B.Cluster headache

Discussion

Cluster headache is characterized by severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes. Headaches are accompanied by one or more of the following: tearing, conjunctival injection, nasal congestion, rhinorrhea, eyelid edema, forehead and facial swelling, miosis, ptosis, and/or sense of restlessness or agitation.

Cluster headaches occur at frequencies of one every other day up to eight times per day. Attacks can occur in series lasting weeks or months, separated by periods of remission. Age of onset is between 20 to 40 years, and men are three times more likely to suffer from the condition than women. Paroxysmal hemicrania has similar symptoms, but attacks are shorter, usually last 2 to 30 minutes and occur 5 or more times per day.

Source: International Headache Society Classification of Headache Disorders, beta version. https://www.ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-2-paroxysmal-hemicrania/

Case 2

A 55-year-old woman describes recently developing bilateral recurrent headaches that wake her up from sleep. Pain is usually moderate and lasts for about 30 minutes. She has been experiencing these headaches about 12 nights per month for the past 4 months. She does not describe any autonomic symptoms or restlessness. What's your diagnosis?

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Answer C. Hypnic headache

Discussion

Hypnic headaches are characterized by recurrent mild to moderate, usually bilateral (in two-thirds of cases) headaches that develop during sleep, cause wakening, and last 15 minutes to 4 hours upon awakening. They typically begin after age 50 and are usually not accompanied by cranial autonomic symptoms or restlessness.

To make the diagnosis, patients should experience 10 or more attacks per month for three or more months. Most sufferers describe persistent, daily or near daily headaches.

Source: International Headache Society Classification of Headache Disorders, beta version. https://www.ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-2-paroxysmal-hemicrania/

Case 3

A 45-year-old man who suffers from constipation describes experiencing 4 episodes of bilateral headache suddenly brought on when he strains to produce a bowel movement. These headaches are at their worst when they first start, and last about a minute. He describes pain that is bilateral and posterior, and sometimes accompanied by vertigo. What's your diagnosis?

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Answer D. Primary cough headache

Discussion

Primary cough headache usually affects individuals over age 40, and is brought on by coughing, straining, or the Valsala maneuver. It is characterized by sudden onset headache in which pain peaks almost immediately. Pain is usually bilateral and posterior; lasts between one second and two hours; and is accompanied by vertigo, nausea, and sleep dysfunction in two-thirds of patients.

The condition is rare and affects about 1% or less of headache sufferers. The majority of these patients have Arnold-Chiari malformation type I.

Source: International Headache Society Classification of Headache Disorders, beta version. https://www.ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-2-paroxysmal-hemicrania/