Gene Fiback: A 57-Year-Old Accountant With Severe Episodic Unilateral Retro-orbital Headaches With Associated Neurologic Symptoms





Learning Objectives





  • Learn the common types of headache.



  • Understand the difference between primary and secondary headaches.



  • Develop an understanding of clinical presentation of specific headache types.



  • Develop an understanding of the treatment of specific headache types.



  • Develop an understanding of the differential diagnosis of headache.



  • Understand the gender predilection of specific headache types.



  • Learn how to identify factors that cause concern.



Gene Fiback





Gene Fiback is a 57-year-old accountant with the chief complaint of, “It feels like someone is jamming a red-hot poker into my eye.” He explained, “Doctor, I am afraid to go to sleep at night because every night, about 90 minutes after I go to sleep, bam, the headache hits. I am sound asleep and, bam, the headache wakes me up. The pain is really bad, like nothing you can imagine. I have to get up, and I just pace. Sometimes I feel like banging my head against the wall to make the pain stop. It’s really bad, unimaginably bad, like the devil is jamming a red-hot poker into my eye. It also hurts in my temple. It goes on for about an hour and then it stops. It takes me another hour to get calmed down, and I try to get some sleep. Doctor, every spring they come like clockwork and after a couple of months, they go away. And then, bam, the fall comes, and they are back again. This has been going on for the last 12 to 15 years, and I don’t know how much longer I can take it. I am just so worn down.”


I asked Gene if he had any symptoms other than the pain and he nodded and said that when the pain hits, the eye on his affected side waters profusely and his nose runs like crazy. “Doctor, some nights I can go through an entire box of Kleenex. My wife tells me that my face gets red and my eyelid droops. I am getting all the broken blood vessels on my face. I look like a drunk, but, Doctor, let me tell you, the last thing I am going to do is take a drink. Booze makes the headaches worse. I came in to see you with this round of headaches to see if there is anything new on the market that can help me. Over the past few years, it seems like the headaches are getting worse. Each year I get a little less headache-free time. Bam, every spring and fall like clockwork, then they go away. I pray they won’t come back, but bam, there they are again. Something’s got to give. I don’t know how much longer I can go on.” I reassured Gene that I would do everything I could to help him get these headaches under control.


I asked Gene if he had identified anything that triggered his headache and he said, “Booze definitely, high altitude for sure, I can’t fly or go to Vail anymore, and as crazy as it may sound, Chinese food.” I asked Gene if he knew whether he was going to get a headache before the headache actually started, and he said not really. “I am just fine when I go to bed, and bam, I get woken up from a sound sleep and I am really in trouble. The pain is just the worst.”


I asked Gene what made it better, and he said, “Really nothing. I’ve tried all of the usual over-the-counter medications and they do absolutely nothing. The headaches come on without warning, and after about 8 to 12 weeks, they just disappear. Just like that, they are gone and I pray that they will never come back. But it’s spring and here they are again.”


I asked Gene to use one finger to point at the spot where it hurt the most when the headache came on and he pointed to his left eye. I asked him what the pain was like: an ache, sharp, stabbing, burning. He immediately responded, “It’s like I said, bam, a burning red-hot poker in my left eye. It’s unbearable and there is nothing I can do about it. I just pace and wait it out. It’s driving my wife crazy. Hell, it’s driving me crazy.” I asked whether the headache was on both sides or just one side, and he answered emphatically, “One side. Always the one side.” I asked Gene from the time that he knew he was going to get the headache until the time it was at its worst, was it a period of seconds, minutes, or hours. He said that it was usually at about 50% when it woke him up and within a minute or two, it was going full bore and he was up and out of bed, pacing back and forth, until the headache subsided. It went away “over 10 or 15 minutes.” I said to Gene that several times he mentioned that the headaches were really wearing him down, so I asked if he had ever considered suicide. He said, “Yes, Doctor, but not that often. Just every time I have a headache.” But he went on to say,” Don’t worry, Doc. I know you will get me better.” I told him I would certainly try.


I asked Gene if I could examine him and he said, “Sure, but there is not much to see. I just hope you have a trick up your sleeve. You just have to get rid of these headaches. I’m just about played out.” On physical examination, Gene was afebrile. His respirations were 16, and his pulse was 78 and regular. His blood pressure was 126/80. There were no cranial abnormalities. His head, eyes, ears, nose, throat (HEENT) examination was completely normal, as was his fundoscopic examination. Specifically, there was no anisocoria. His temporal arteries were normal bilaterally. I noted multiple telangiectasias on Gene’s nose and cheeks, and his skin over the malar regions had a peau d’orange appearance. Deeply furrowed glabellar skin was also noted. His neck examination was normal, and no myofascial trigger points were identified. His cardiopulmonary examination was normal, as was his thyroid. There was no adenopathy. His abdominal examination revealed no abnormal mass or organomegaly, and there was no rebound tenderness present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and his deep tendon reflexes were normal. The remainder of his neurologic examination was completely normal. Gene’s mental status exam was within normal limits.


Key Clinical Points—What’s Important and What’s Not


The History





  • Episodic headaches that began in the patient’s late third decade



  • Headaches of consistent chronobiologic pattern with peak headache occurrence in the spring and fall



  • Headaches characterized by headache-free periods



  • Headache consistently occurs approximately 90 minutes after the patient goes to sleep



  • Headache pain is severe



  • Headache is unilateral



  • Headache is retro-orbital with a deep burning, stabbing quality



  • Headaches are associated with profuse lacrimation and rhinorrhea on the affected side



  • No prodrome or aura



  • No fever or chills



  • Patient denies significant nausea and vomiting associated with the headache



  • Headaches associated with suicidal ideation



The Physical Examination





  • Patient is afebrile



  • Normal fundoscopic exam



  • Examination of the cranium is normal



  • Neurologic exam is normal



  • Telangiectasias over patient’s nose and cheeks



  • Peau d’orange appearance of skin over malar areas



  • Deeply furrowed glabellar skin



Other Findings Of Note





  • Normal cardiovascular examination



  • Normal pulmonary examination



  • Normal abdominal examination



  • No peripheral edema



  • Normal upper and lower extremity neurologic examination, motor and sensory examination



What Tests Would You Like to Order?


The following test was ordered:




  • Magnetic resonance imaging (MRI) of the brain



Test Results


The MRI of the brain was normal.


Clinical Correlation—Putting It All Together


What is the diagnosis?


Cluster headache


The Science Behind the Diagnosis


Clinical Syndrome


Cluster headache derives its name from the headache pattern—that is, headaches occur in clusters, followed by headache-free remission periods. Cluster headache is a primary headache that is included in the group of headaches known as the trigeminal autonomic cephalgias. Unlike other common headache disorders that affect primarily female patients, cluster headache is much more common in male patients, with a male-to-female ratio of 5:1. Much less common than tension-type headache or migraine headache, cluster headache is thought to affect approximately 0.5% of the male population. Cluster headache is most often confused with migraine by clinicians who are unfamiliar with the syndrome; however, a targeted headache history allows the clinician to distinguish between these two distinct headache types easily ( Table 4.1 ).


Apr 16, 2022 | Posted by in PAIN MEDICINE | Comments Off on Gene Fiback: A 57-Year-Old Accountant With Severe Episodic Unilateral Retro-orbital Headaches With Associated Neurologic Symptoms
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