Clinical Reasoning: A 62-year-old migraineur with a new kind of headache attacks

Abstract

A 62-year-old man presented with novel headache attacks with acute onset 4 weeks previously strictly confined to the right side. The attacks occurred almost daily, often after midnight, lasting 1 to 3 hours, occasionally longer. The pain was localized around and behind the right eye. The pain intensity was excruciating and the pain quality pulsatile. Ipsilateral lacrimation, conjunctival injection, and prominence of the temporal artery accompanied these attacks. During the attacks, the patient reported a sense of restlessness. Alcohol consumption and physical activity provoked attacks. No recent major trauma was identified. In his personal history, the patient had had tension-type headache and mainly left-sided migraine-like headache attacks for many years. The latter were of a hammering quality, irradiating from the occipital to the frontal region, and accompanied by nausea, photophobia, and phonophobia. In comparison, the new onset current attacks clearly differed from the previous attacks in terms of location, pain quality, intensity, frequency, duration, and attendant symptoms. Ancillary diagnoses included arterial hypertension, treated with amlodipine, and α-1 antitrypsin deficiency. Family history revealed a twin brother, who died of aneurysmal subarachnoid hemorrhage 6 years previously. Several relatives had migraine. On clinical examination, reduced width of the palpebral fissure on the right side compared to the left (ptosis), right miosis, and anhidrosis of the forehead (figure 1, A and B) were noticed. These findings persisted during the pain-free interval. Figure 1 Complete right Horner triad (A) Right eye “ptosis” (or, more correct, reduced width of the palpebral fissure on the right side compared to the left) and miosis. (B) Right forehead anhidrosis, visualized using ponceau dye. ### Questions for consideration: 1. How would you classify these new onset headache attacks? 2. Are there any atypical features or red flags pointing to a secondary headache? GO TO SECTION 2 At first glance, the patient's complaints and clinical findings match the criteria of the International …