Cases and Clinical Pearls
Turning to cases from his own experience, Dr. Purdy described a 58-year-old woman who presented to him with a three-year history of left-sided, throbbing headache that was associated with a drooping left eyelid and eye congestion. The patient’s neurologic examination and imaging were normal, and her headache did not respond to migraine medication. At Dr. Purdy’s request, she sent him a digital photograph of the drooping eyelid and eye congestion during an attack. The patient was diagnosed with hemicrania continua, which is characterized by continuous unilateral pain accompanied by ptosis or other autonomic features. Dr. Purdy emphasized that spending time on the patient’s history and asking her for the photograph helped him to reach the diagnosis.
Next, he described the case of a 45-year-old woman who presented with sharp pains in her right eye, her left temple, and, occasionally, her left eye. The patient compared her current pain to the stabs of an ice pick, and she said that she had experienced some “regular headaches” in the past that responded to simple analgesics. The patient was diagnosed with primary stabbing headache, formerly known as ice pick headache, which is characterized by repetitive stabs. Dr. Purdy stressed that this headache is common in people with migraine—a fact that was “the secret to this diagnosis.”
In the third case he described, a 56-year-old man presented with occipital headache that he compared to being hit in the back of the head with a baseball bat and that also followed coughing, straining, or a Valsalva maneuver. The patient probably had cough headache, Dr. Purdy said, noting, “Primary thunderclap headache doesn’t look a heck of a lot different, except you leave out the coughing.” In discussing the case, he reiterated that secondary causes of less common headaches can be serious; physicians should look for such causes when they see a cough headache, thunderclap headache, sexual headache, or exertional headache, he said.
Dr. Purdy’s fourth case was that of a 49-year-old woman who presented with 17 headache attacks per day that were accompanied by left-sided tearing, nasal congestion, and rhinorrhea. He said that the headache is “probably episodic paroxysmal hemicrania,” which usually occurs more than five times per day and is accompanied by one or more of several features that include tearing, nasal congestion, and rhinorrhea. This diagnosis was supported by her complete response to indomethacin. In addition, he noted that probable paroxysmal hemicrania, probable cluster headache, and probable SUNCT are all probable TACs and that “the secret to diagnosing these [headaches] is the frequency; short duration; autonomic signs and lack of agitation; seeing an attack, if you can; and ruling out secondary causes.”
Lumpers and Splitters
Dr. Purdy concluded that physicians can be “lumpers,” who lump different conditions together, or “splitters,” who split them into different diagnoses. He added that in the absence of a clear diagnosis, physicians should “say these famous words to yourself and your patient: ‘I do not know!’ You’ll live longer; they’ll do better and find somebody who does know.”