Cluster Headache: The Daily PANCE Blueprint
A 38-year-old man describes attacks of excruciating boring pain behind his right eye that wake him from sleep, last about 45 minutes, and recur one to three times a day. They have happened daily for the past three weeks, and he had a similar stretch last autumn. During an attack his right eye waters and the lid droops, his right nostril runs, and he paces the room unable to sit still. He is completely well between attacks. Neurologic examination and imaging are normal. Which of the following is the most appropriate abortive treatment?
A. High-flow 100% oxygen
B. Oral amitriptyline
C. Oral propranolol
D. Oral acetaminophen
E. Oral verapamil
Answer and topic summary
The answer is A. High-flow 100% oxygen
Severe unilateral periorbital pain with ipsilateral autonomic features — tearing, ptosis, rhinorrhea — plus agitation and a strikingly circadian, seasonal clustering is cluster headache, a trigeminal autonomic cephalalgia. The behavior is a useful discriminator: migraine patients lie still in a dark room, while cluster patients pace and rock because they cannot keep still. The abortive treatment is high-flow 100% oxygen by non-rebreather, typically 12 to 15 L/min for 15 minutes, which aborts most attacks within minutes; subcutaneous sumatriptan is the other first-line abortive. The trap in this question is that every other option is a preventive agent, not an abortive one — verapamil is the first-line prophylactic for cluster, and amitriptyline and propranolol are migraine and tension-headache prophylaxis. Attacks peak and resolve too quickly for an oral analgesic like acetaminophen to be useful at all.
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