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com
MEDICAL DISCLAIMER
Medical Disclaimer: The cases presented
here are fictional patient cases. These
are referenced and created by Ninja Nerd
Inc and are meant for educational
purposes only. This is not meant to
diagnose or treat medical conditions.
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SUBJECTIVE
HPI:
❏ 48 year old male presents with an intense headache
❏ What are the things you need to ask about headache?
❏ OPQRST
❏ He says it started 1 hour ago, ibuprofen hasn't helped and
pacing is the only thing that barely helps, he describes the
headache as stabbing and burning around his left eye and left
forehead which he says feels like radiates behind his left
eye. He grades the pain a 10/10 and says the pain as been
relentless and constant. Patient states he’s never had a
headache like this before
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SUBJECTIVE CONTINUED
PMH: Allergies:
❏ NKDA/NKFA
❏ COPD
Medications:
Social History:
❏ Albuterol inhaler
❏ Smokes 1 pack/day ❏ Ipratropium bromide
❏ Drinks 1-2 alcoholic inhaler
❏ Inhaled corticosteroid
beverages a week
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Physical exam
Physical Exam Findings:
❏ General
❏ Male who appears in pain
❏ HEENT
❏ Conjunctival/ocular hyperemia of left eye,
Vitals: ptosis of left upper eyelid
❏ Excessive lacrimal secretions
❏ Serous rhinorrhea
❏ BP:138/74 ❏ Neuro
❏ AAOx4
❏ HR:125 ❏ Right pupil> left pupil but both reactive,
EOMI, visual fields full, Uvula, palate and
❏ RR: 18 tongue midline
❏ 5/5 strength in all 4 extremities
❏ SpO2: 98% on room ❏ Intact to Light touch
❏ Cardiovascular
air ❏ Tachycardic, regular rhythm, no murmurs,
rubs or gallops
❏ Temp: 98.6 ℉ (37℃) ❏ Pulmonary
❏ CTABL, no wheezing or rales
❏ Abdomen
❏ soft , normoactive bowel sounds, no TTP
❏ PVS
❏ +2 dorsal pedal pulses and no LE edema
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Any red flag signs?
❏ Yes OR No?
❏ What do red flag signs
tellAfraTafreeh.com
us?
❏ Secondary headaches
What's your likely diagnosis?
❏ A. Migraine with aura
❏ B. Cluster headache
❏ C. Migraine without aura
❏ D. Tension headache
What objective and subjective info support that diagnosis?
❏ Subjective:
❏ Headache characteristics
❏ Unilateral
❏ Frontal, orbital, supraorbital with retro orbital
radiation
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❏ Stabbing burning
❏ Slightly improved by pacing
❏ Constant relentless headache for past hour
❏ Objective:
❏ Ocular/conjunctival hyperemia
❏ Lacrimation and nasal secretions
❏ Partial horner's
❏ Miosis and ptosis
Any imaging ?
❏ Would you order a CT/MRI → Yes OR No?
❏ YES → Since this is the patients first cluster headache, one
should obtain a CT/MRI of brain to rule out any secondary
headache
❏ Thankfully, imaging was normal
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What is first line treatment?
❏ A. IV ketorolac 30mg
❏ B. Non Rebreather 6-12L/min
❏ C. Verapamil
❏ D. IV Fentanyl 25 mcg
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What else can i give ?
❏ A. IV ketorolac 30mg
❏ B. 1mg Dihydroergotamine IM
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❏ C. Sumatriptan 6mg SQ
❏ D. IV fentanyl 35mcg
What’s a contraindication to triptans?
❏ A. Peripheral artery disease
❏ B. Coronary artery disease
❏ C. Pregnancy
❏ D. All of the above
Headache aborted, what about prevention?
❏ A. Verapamil 120 mg TID
❏ B. Prednisone + Verapamil
❏ C. Ibuprofen
AfraTafreeh.com 600 mg TID
❏ D. Prednisone 50 mg QD tapered over 10 days
What risk factors can be modified?
❏ A. Smoking cessation
❏ B. Reduce alcohol intake
❏ C. Reduce stressors by watching Ninja Nerd
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❏ D. All of the above
Q&A
