Student: Mohammed Islam
Date: 9/22/2026
Headache Case Study
Patient Background
49-year-old male
Working as a construction manager for the past 20 years
Intermittent low back pain
Other co-morbidities include hypertension and diabetes type II, both of which are
controlled with medication
Patient has received previous outpatient care for his low back pain and describes that he
had a decrease in pain for a period of time before the pain returned in his low back.
Subjective
The patient is a 49-year-old African American male. The patient is seen by the PCP at a Primary
Care Clinic for a routine exam. He explains that he has been experiencing these “headache
attacks” for the past month around this time of day.
The patient reports that since he started working late night shifts at the construction company one
month ago, he was forced to nap throughout the afternoon in order to be safe to work in the early
hours of the morning. However, when he would wake up he would experience excruciating,
burning pain above and behind his left eye. The pain was so severe that he could “feel something
pulsating on the side of my head.” Once the pain subsided 20-30 minutes later, the patient looked
in the mirror and saw that his left eyelid was red, swollen, and teary. The patient explains that
these headaches have continued, and always seem to start after he wakes up at 5 p.m. (the time of
this evaluation), approximately 3-4 times per week. When asked if lying down reduced the
symptoms, the patient explained that laying down actually made the pain worse, so he is forced
to pace around. However, when asked if his pain ever increases during an attack, the patient
reports that the pain is often constant. In addition, the patient denies an increase in symptoms
while staring at lights. The PCP asks if he ever feel nauseous, dizzy or confused. The patient
denies any of these symptoms and believes these headaches are just “his body’s way of adjusting
to the change in sleep patterns.”
Past Medical History: CAD, DM, HTN
Family History: CAD, DM
Risk Factors: 1 pack/ day smoker, 1-2 Beer/ day
, Objective Measurements
Heart Rate: 88
Blood Pressure: 122/ 80 (Controlled with Lisinopril)
Respiratory Rate: 16
Pain Scale: During attack 9/10
Sensation: Intact
Reflexes: Intact
Nystagmus: Negative.
Visual Field Cut: Negative
PERRLA
A&O x3
Please answer the following questions:
1. What are your top four (4) differential diagnoses - explain your rationale for each.
Cluster headache: Patient is complaining that lying down doesn’t help improve his
headache and makes the pain worse, this is commonly seen with a cluster headache (May,
2026). Patients are restless and pace around with cluster headaches. His headache lasting
20-30 minutes and occurring 3-4 times per week also meet criteria for a cluster headache.
Other indicators of cluster headache include the unilateral presentation of his symptoms
and the involvement of the periorbital area (May, 2026).
Migraine headache: The patient’s sleep pattern has dramatically changed and one of the
triggering factors is a disruption to routine activity (Rogers, 2023, p. 597). The unilateral,
pulsatile and severe pain support the diagnosis. Less likely due to the absence of
photophobia, nausea and vomiting (Rogers, 2023, p. 597).
Trigeminal neuralgia: Presence of severe pain and a unilateral presentation is seen with
this diagnosis (May, 2026). Less likely as trigeminal neuralgia lasts for seconds to
minutes, whereas this patient’s symptoms last for 20-30 minutes. Cluster headache is one
of the diagnosis in this case and trigeminal neuralgia also needs to be included because
some patients have these conditions together, known as cluster-tic syndrome (May,
2026).
Paroxysmal hemicrania: The burning description, severe pain and the unilateral
presentation is consistent with this diagnosis (Matharu & Cohen, 2026). Agitation and
pacing are also seen with paroxysmal hemicrania. The duration of the symptoms lasts for
2-30 minutes, which is present in this case. Less likely as the symptoms can last up to
multiple hours. In addition, we can exclude this diagnosis as the attacks seen with
paroxysmal hemicrania are more frequent throughout the day, ranging from 1-40 per day
(Matharu & Cohen, 2026).
Date: 9/22/2026
Headache Case Study
Patient Background
49-year-old male
Working as a construction manager for the past 20 years
Intermittent low back pain
Other co-morbidities include hypertension and diabetes type II, both of which are
controlled with medication
Patient has received previous outpatient care for his low back pain and describes that he
had a decrease in pain for a period of time before the pain returned in his low back.
Subjective
The patient is a 49-year-old African American male. The patient is seen by the PCP at a Primary
Care Clinic for a routine exam. He explains that he has been experiencing these “headache
attacks” for the past month around this time of day.
The patient reports that since he started working late night shifts at the construction company one
month ago, he was forced to nap throughout the afternoon in order to be safe to work in the early
hours of the morning. However, when he would wake up he would experience excruciating,
burning pain above and behind his left eye. The pain was so severe that he could “feel something
pulsating on the side of my head.” Once the pain subsided 20-30 minutes later, the patient looked
in the mirror and saw that his left eyelid was red, swollen, and teary. The patient explains that
these headaches have continued, and always seem to start after he wakes up at 5 p.m. (the time of
this evaluation), approximately 3-4 times per week. When asked if lying down reduced the
symptoms, the patient explained that laying down actually made the pain worse, so he is forced
to pace around. However, when asked if his pain ever increases during an attack, the patient
reports that the pain is often constant. In addition, the patient denies an increase in symptoms
while staring at lights. The PCP asks if he ever feel nauseous, dizzy or confused. The patient
denies any of these symptoms and believes these headaches are just “his body’s way of adjusting
to the change in sleep patterns.”
Past Medical History: CAD, DM, HTN
Family History: CAD, DM
Risk Factors: 1 pack/ day smoker, 1-2 Beer/ day
, Objective Measurements
Heart Rate: 88
Blood Pressure: 122/ 80 (Controlled with Lisinopril)
Respiratory Rate: 16
Pain Scale: During attack 9/10
Sensation: Intact
Reflexes: Intact
Nystagmus: Negative.
Visual Field Cut: Negative
PERRLA
A&O x3
Please answer the following questions:
1. What are your top four (4) differential diagnoses - explain your rationale for each.
Cluster headache: Patient is complaining that lying down doesn’t help improve his
headache and makes the pain worse, this is commonly seen with a cluster headache (May,
2026). Patients are restless and pace around with cluster headaches. His headache lasting
20-30 minutes and occurring 3-4 times per week also meet criteria for a cluster headache.
Other indicators of cluster headache include the unilateral presentation of his symptoms
and the involvement of the periorbital area (May, 2026).
Migraine headache: The patient’s sleep pattern has dramatically changed and one of the
triggering factors is a disruption to routine activity (Rogers, 2023, p. 597). The unilateral,
pulsatile and severe pain support the diagnosis. Less likely due to the absence of
photophobia, nausea and vomiting (Rogers, 2023, p. 597).
Trigeminal neuralgia: Presence of severe pain and a unilateral presentation is seen with
this diagnosis (May, 2026). Less likely as trigeminal neuralgia lasts for seconds to
minutes, whereas this patient’s symptoms last for 20-30 minutes. Cluster headache is one
of the diagnosis in this case and trigeminal neuralgia also needs to be included because
some patients have these conditions together, known as cluster-tic syndrome (May,
2026).
Paroxysmal hemicrania: The burning description, severe pain and the unilateral
presentation is consistent with this diagnosis (Matharu & Cohen, 2026). Agitation and
pacing are also seen with paroxysmal hemicrania. The duration of the symptoms lasts for
2-30 minutes, which is present in this case. Less likely as the symptoms can last up to
multiple hours. In addition, we can exclude this diagnosis as the attacks seen with
paroxysmal hemicrania are more frequent throughout the day, ranging from 1-40 per day
(Matharu & Cohen, 2026).
