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Consultation Report
Patient: John Doe · Date: Jan 1, 2025
Chief complaint
Piercing headaches.
History of present illness
A 17-year-old right-handed male with a one-month history of continuous, extremely severe, sharp, splitting, and shooting pain localized to the left eye. Pain occurs daily with no headache-free days and is often disabling, waking him from sleep and peaking within 2–5 minutes. Associated symptoms include left-sided tearing, ptosis, eye redness, restlessness, and anxiety during attacks. No focal neurological deficits, fever, neck stiffness, infection, or trauma reported.
Assessment
Continuous, strictly unilateral periorbital pain with prominent autonomic features raises concern for a trigeminal autonomic cephalalgia. Chronic cluster headache is possible but atypical due to continuous pain. Hemicrania continua is also considered; response to indomethacin is unknown. Secondary headache must be excluded. Diagnostic confidence is limited due to missing neuroimaging, indomethacin trial, and prior episode history.
Presumptive differential diagnosis
Chronic cluster headache — severe unilateral periorbital pain with autonomic features, though continuous pain is atypical.
Secondary headache disorder — structural, vascular, or orbital pathology must be ruled out.
Primary concern
Chronic cluster headache remains the leading consideration, but secondary causes must be excluded given the continuous severe presentation. (ICHD-3: 3.1.2)
Alternate diagnoses
Hemicrania continua and secondary headache disorders remain possible. Neuroimaging and further evaluation are required. (ICHD-3: 3.4, 6)
Plan
Deferred to treating clinician.
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