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Neurology Trigeminal Autonomic Cephalalgias These primary headache disorders are characterized by severe unilateral pain in the distribution of the first division of the trigeminal nerve (periorbital, frontal, temporal) accompanied by ipsilateral autonomic symptoms (nasal congestion or rhinorrhea and ptosis or miosis). These headaches are differentiated from each other by the duration of pain and frequency of attacks. The most common is cluster headache, which is characterized by: Cluster Headathe: Ptosis, miosis, and increased tears in the left eye in a patient . orbital or periorbital pain lasting 15-180 minutes with cluster headache. Reprinted from Hale N, Paauw DS. Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and o occurrence several times per day new considerations in diagnosis and management. Med Clin North Am.2014 . headaches repeating over weeks, then disappearing for May;98(3):505-27. IPMID: 24758958], with permission from Elsevier. months or years Cluster headache can be treated with oxygen inhalation or subcutaneous sumatriptan. Verapamil may help prevent cluster headache. Selected Secondary Headache Disorders Diagnosis Secondary headache disorders tlpically display "red flags": o first orworst headache o abrupt onset or thunderclap attack r progression or fundamental change in headache pattern . abnormal physical examination findings o neurologic symptoms lasting >1 hour o new headache in persons >50 years old . new headache in patients with cancer, immunosuppression, or pregnancy o association with alteration in or loss of consciousness . headache triggered by exertion, sexual activity, or Valsalva maneuver Testing Order as appropriate: o MRI over CT in nonemergency situations . CT for suspected acute ICH r ESR or CRP for suspected giant cell arteritis o LP for suspected infectious or neoplastic meningitis or disorders of intracranial pressure DOil'T BE TRIGKED . EEG has no role in the assessment of headache disorders. 249