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Chronic primary unilateral headaches fall into one of five categories: chronic cluster headache, chronic paroxysmal hemicrania, hemicrania continua, cervicogenic headache, and SUNCT syndrome. Overlap between types is recognised. Although the differentiation of these is sometimes difficult, there are important therapeutic implications—for example, indomethacin has a dramatic effect on chronic paroxysmal hemicrania but is less effective in chronic cluster headache. Here, a patient with paroxysmal unilateral headaches, occurring precisely on the same day of the week and at the same time, is described.
A 57 year old man presented with episodic, right sided, moderate to severe headaches of 9 months' duration. He developed these always on a Monday at 1300 hours. The headaches were sharp and throbbing with the maximum pain behind the right eye. The headache then radiated to the back of the head without crossing the midline. The pain was felt in paroxysms each lasting several minutes. He did not experience any visual symptoms, nausea, nasal congestion, lacrimation, or ptosis. Initially the total duration of the headaches was about 10 hours but it became progressively longer, remaining until Wednesday on some occasions. They were not related to the consumption of food and he did not go out drinking on Sunday nights.
At the age of 20, he had had four episodes of severe headache on the right on four consecutive days after breaking rest during a week of night shifts as a warehouseman. In between the Monday “lunchtime headaches”, he remained well. He had no personal or family history of migraine. He was taking propranolol for mild hypertension. His examination was normal. There was mild cervical spondylosis on plain radiology. Brain CT showed minor atrophy.
A diagnosis of chronic paroxysmal hemicrania was made, and he was prescribed indomethacin (50 mg three times on Mondays). With this his headaches were delayed until Tuesday morning and the duration of the headaches was reduced to less than 24 hours. The headaches also became less predictable. A more protracted course of indomethacin rendered him headache free.
Review of this man's headache history suggests that the episode he had when aged 20 was probably an isolated “cluster” headache. The more recent, highly predictable, right sided headaches on Monday afternoons were unusual. The predictability of these was such that he could time it precisely to 1300 hours. Their characteristics were not classic for chronic paroxysmal hemicrania, in which attacks last between 20 and 30 minutes and are accompanied by ipsilateral nasal congestion and lacrimation.1 Attacks of chronic paroxysmal hemicrania can, however, have clockwork regularity and are abolished by indomethacin.1 Headaches in this case are also different from chronic cluster headache as the paroxysms occurred many times throughout the day (repetition rate 12–16/day) and the total duration of an “attack” could be up to 72 hours. Recently another variant of chronic paroxysmal hemicrania—hemicrania continua—has been described2 and these headaches are non-paroxysmal and continuous. The degree of cervical spondylosis in this patient was mild, and furthermore the nature of the attacks was not that of cervicogenic headache. SUNCT syndrome is a type of paroxysmal unilateral headache consisting of short lasting, unilateral, neuralgiform headaches with conjunctival injection and tearing.3 4 Patients have up to 30 paroxysms/hour, occurring once or twice a day.3 This diagnosis is also highly unlikely in our patient, with his clinical presentation and therapeutic response. It was thought that this man's headaches were most probably due to chronic paroxysmal hemicrania evolving from a possible early “cluster” attack, supporting the suggestion that a common pathophysiology underlies these “trigeminal-autonomic cephalalgias”.4 The precise predictability of the Monday afternoon headaches is fascinating, and unexplained.
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