Since on our ward we are dealing with strokes mainly, there is a tendency to forget basic neurologic knowledge, in particular in emergency settings. This happened recently in the following case: a 43 yo storage worker comes at 2 am into the ER, complaining about 4 months of unilateral headache, non side-shifting, with ugly exacerbations from his usual 4 to 8-9/10. Upon examination you discover a Horner syndrome and some tearing and noserunning. Interestingly he describes unilateral photophobia.
This is not a dissection, neither an SAH. As with all headaches history is the way to get to the truth, and maybe some treatment. Here are some important questions to ask:
- Does the headache shift side?
- Is it diurnally fixed?
- Worse on lying than on standing?
- Better with rest?
- Loccally triggerable?
- Visual disturbance?
- Photo-/phono-/osmo-/kinetophobia? Unilateral?
- What triggers are there?
- What drugs help?
In all the trigeminoautonomic cephalagias, you have to get a picture (i.e. MRI) eventually, but this should not preclude from treatment. Try oxygen 100%, triptans and indomethacin. Our case does have hemicrania continua, which by definition should react to this unique drug – but this is recently doubted.
References: in addition to the above article try the series of Peter Goadsby’s lectures on headache on YouTube.