A 40-year-old woman presents with recurrent episodes of sudden-onset unilateral periorbital pain lasting 15-45 minutes, occurring up to 8 times per day, associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, and ptosis/miosis. Episodes cluster for 6-8 weeks. What is the diagnosis and the drug of choice for acute attacks?
- A Paroxysmal hemicrania — indomethacin (absolute diagnostic response)
- B Migraine with aura — oral triptan therapy
- C SUNCT syndrome — lamotrigine prophylaxis
- D Cluster headache — 100% oxygen at 12-15 L/min via non-rebreather mask and/or subcutaneous sumatriptan ✓
Explanation
Cluster headache is characterized by unilateral severe periorbital or orbital pain (15-180 min), multiple daily attacks, autonomic features (lacrimation, rhinorrhea, conjunctival injection, Horner's), and episodic clustering. Acute attacks are best treated with high-flow 100% oxygen (12-15 L/min for 15-20 min) and/or subcutaneous sumatriptan 6 mg — both achieve rapid relief. Paroxysmal hemicrania attacks last 2-25 min and have absolute response to indomethacin, distinguishing it from cluster headache. SUNCT attacks last seconds to minutes. The autonomic features and attack duration overlap but treatment diverges sharply between these TACs.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.