A 41-year-old man complains of terrible headache. It started an hour ago, without warning, while stressed at work. It affects the right side of his head. He scores it ‘11/10’ in severity. When asked, he agrees that light does bother him a little. He had a similar episode six months ago, experiencing very similar headaches over 2 weeks which resolved spontaneously. On observation, he looks quite distressed and prefers to pace up and down, unable to sit still. What is the diagnosis?
A. Subarachnoid haemorrhage
B. Tension headache
C. Intracerebral haemorrhage
E. Cluster headache
(E) Cluster headache (E) is more common in men and is classically excruciating, unilateral headache associated with autonomic features such as miosis, ptosis, conjunctival injection, tearing, sensation of nasal congestion and facial flushing. Timing is important, headaches occur in clusters of multiple episodes over a couple of weeks, then resolve spontaneously only to reoccur months to years later. They are not associated with aura or signs of raised intracranial pressure. Although the headache is severe and of acute onset in this instance, with possible photophobia, there is nothing in the stem to suggest raised intracranial pressure, such as papilloedema, nausea and vomiting or meningism, such as nuchal rigidity (A). More importantly, he has had similar episodes in the past. The timing and autonomic symptoms point to cluster headache. Tension headache (B) is classically associated with stress, reported as a tight band around the head and is much more benign. Intracranial haemorrhage (C), depending on location, is likely to cause focal signs or, especially if posterior fossa, signs of raised intracranial pressure and coning. Hypertension is an important risk factor. Migraine (D) classically is heralded by an aura and is associated with nausea and vomiting with osmo- (smell), phono- (sound) and photophobia. Patients prefer to curl up in a dark, quiet room, whereas patients with cluster headache feel the need to move around.