Fictional

A 22 year old woman presents with multiple episodes of right sided periorbital and temporal headache, in association with lacrimation, rhinorrhea, nausea, and vomiting. The episodes occurred up to 5 times a day, and lasted around an hour each.

These attacks first started 2 years ago. All investigations, including a MRI brain, were normal. She was unresponsive to treatments for cluster headache and migraine.

She is a frequent visitor to the outpatient department. Her records reveal suspicions of her using artificial tears to simulate tearing, and the fact that actual vomiting was not witnessed by any medical personnel.

Select Relevant Investigations
CT Angiogram Brain

Performed

The CT Angiogram of the brain appears completely normal
CSF Analysis

Performed

Appearance: clear
Cell count: 2 cells/mm3 (<5 cells/mm3)
Protein: 25 mg/dl (15-40 mg/dL)
Glucose: 58 mg/dL (½ to ⅔ of blood glucose)
Random Blood Sugar: 97 mg/dL
Temporal Artery Biopsy

Performed

You wonder if a temporal artery biopsy is really indicated.
Beck Depression Inventory

Performed

Beck Depression Inventory (BDI) score: 11/63

Select Relevant Management
Sumatriptan
Propranolol
Oxygen via Face Mask
Cognitive Behavioral Therapy