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A 43-Year-Old Man With New Headaches

Ronald N. Rubin, MD1,2Series Editor

    1Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
    2Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania

    Rubin RN. A 43-year-old man with new headaches. Consultant. 2022;62(10):e38-e41. doi:10.25270/con.2022.09.000002

    The author reports no relevant financial relationships.

    Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140 (


    A 43-year-old man presents after experiencing 2 days of an unusual headache. On each of the previous 2 days, he first noted blurry vision accompanied by flashes of light in the left eye, which expanded for roughly 30 min and were followed by a throbbing left-sided headache. The visual symptoms abated, but the headache remained. He took 400 mg of ibuprofen, which yielded significant but not complete pain relief. He was slightly nauseated, but there was no emesis. There were no further ocular or neurologic symptoms. By the evening of day 2, he was feeling better and slept through the night without pain. He awoke the next morning feeling well but later in the day experienced symptoms again, which prompted him to present to the clinic.

    History. He is an otherwise healthy man with no other major medical diagnoses by history. He exercises regularly. His only medications are occasional ibuprofen for minor orthopedic issues. No history of falls or head trauma is noted.

    Physical examination. Testing revealed vital signs within normal limits. Specifically, the patient was afebrile and normotensive. Results of a head, eyes, ears, nose and throat examination showed his pupils were equal, round, reactive to light and accommodation and had full and normal extraocular movement. A fundoscopy performed in the office was negative for obvious retinal hemorrhage, and vision in both eyes seemed normal.

    A neurological examination revealed intact cranial nerves II through XII with no focal or lateralizing signs. Routine blood studies (eg, complete blood cell count, basic and comprehensive metabolic panels) were all within normal limits.

    Which of the following is the most accurate statement regarding this patient?

    A. He is experiencing the onset of cluster headache syndrome.

    B. Early and aggressive symptom-relief programs that include opioids should be initiated to prevent progression into a chronic form.

    C. He has experienced a severe retinal detachment and should have an urgent referral to an ophthalmologist.

    D. The clinical diagnosis of migraines is most likely, and therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) can be initiated.

    E. He has experienced a thunderclap headache and requires emergency neurosurgical intervention.

    Answer and discussion on next page.