A 44 years old male smoker presents with a 9-year history of current headaches occurred twice-monthly, always in the early hours of the morning. The headaches have increased to an average of 2 episodes per day. The acute episodes can occur at any time, and last between 2 and 4 hours. He always has a nocturnal event. Attacks are triggered immediately after drinking alcohol or with strong smells. The pain is excruciating and focused around his right eye. He becomes severely agitated during attacks, often pacing the room or rocking back and forth. On examination, his right eye is reddened with lacrimation and drooping of the eyelid, and right-sided rhinorrhea. What are the most important differential diagnoses?

Of the relevant differential diagnoses, it is important to rule out pituitary or brain tumor, increased intracranial pressure, meningeal irritation, trigeminal neuralgia, subarachnoid hemorrhage, transient ischemic attack and temporal arteritis.

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This post was written by Omar Rifai