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Case 31
A 39 year-old man comes to the office complaining of head pain for a month that is so severe “that if you
canʼt do something to make it go away, I will.” He describes excruciating deep pain behind the right eye,
with tearing, redness, and nasal stuffiness, but no nausea or vomiting. The pain escalates over minutes
and lasts for about an hour. He has had several episodes daily since onset, mostly at night. Over-thecounter pain medications have provided no relief. His wife says he grabs his head and paces when he is
in pain; she has noticed his right eyelid is slightly droopy during an episode. He has no history of head or
neck trauma or prior problems with headache and there have been no visual symptoms. He takes no
medications and has no chronic medical conditions.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? Include doses for 1
medication you might prescribe for this patient along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about his condition and about any proposed
therapy?
Case 31
A 39 year-old man comes to the office complaining of head pain for a month that is so severe “that if you
canʼt do something to make it go away, I will.” He describes excruciating deep pain behind the right eye,
with tearing, redness, and nasal stuffiness, but no nausea or vomiting. The pain escalates over minutes
and lasts for about an hour. He has had several episodes daily since onset, mostly at night. Over-thecounter pain medications have provided no relief. His wife says he grabs his head and paces when he is
in pain; she has noticed his right eyelid is slightly droopy during an episode. He has no history of head or
neck trauma or prior problems with headache and there have been no visual symptoms. He takes no
medications and has no chronic medical conditions.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? Include doses for 1
medication you might prescribe for this patient along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about his condition and about any proposed
therapy?