PAINE #PANCE Pearl – Neurologic


A 47yo man is being evaluated for a headaches that he describes as “someone jabbing my brain through my eye”. He reports these headaches occur several times a day for the past several weeks, lasting only for a minute, and only affecting his right side of this head. While speaking with him, he has another episode and you notice his eye becomes red and injected with significant tearing and nasal drainage present. On closer examination, he also notice his pupil on the affected side is constricted and he has a mild lid lag.

  1. What is the treatment protocol of choice for this patient?


This patient is suffering from a classic cluster headache due to hypothalmic activation of the trigeminal-autonomic reflex. Abortive treatment for this type of headache includes:

  • 100% oxygen via non-rebreather
  • Sumatriptan 6mg SQ
  • 4-10% Lidocaine 1mL IN
  • Dihydroergotamine 1mg IV

Verapamil 240mg daily with a prednisone 60-100mg daily bridge for 5 days can be used for prevention.

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