This is a rare presentation of a cluster-like headaches which poses diagnostic and management dilemmas in light of two secondary headache pathologies being identified.
A female in her seventies presented with a 12 month history of worsening intensity and frequency left-side locked, excruciating, searing and stabbing craniofacial pain with associated eye watering and orbital oedema. Duration was 1–2 hours up to 4 times per week. There was never more than 3 weeks between attacks and was pain free in-between. There was a long term milder infrequent but similar headache and migraine with aura in her twenties reported.
The atypical features (older age of onset, female, frequency and limited autonomic features) as well as pattern change and lack of remission triggered further investigation. Her MRI head showed both a left cavernous sinus aneurysm and a pituitary adenoma.
Both cavernous sinus aneurysm and pituitary pathologies have individually been shown to ‘mimic’ cluster headache but dual pathology hasn’t been reported. Several authors suggest screening for pituitary pathology in patients with TACs and others for vascular lesions. However this can add an additional management dilemma when the case could be a Victim of Modern Imaging Technology (VOMIT) (incidentalomas).
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