A Less Common Indication for High-Flow Oxygen

A look back at an ER visit for an ongoing painful headache.
By Marven Ewen, MD
Medical Director
Late one evening, a 36-year-old man presented to the ER with a severe stabbing right sided headache. As he rocked back and forth holding his head he told me that he had been getting this same headache intermittently throughout the day and night over the past few days. He said last year the headaches recurred like this every day for about 6 weeks.

He described a sharp, stabbing headache in the area of his right periorbital area that would occur several times a day lasting approximately 45 min to an hour. He came to the ER because he said he just couldn’t take it anymore. He had tried aspirin and ibuprofen without relief.

Other than the prior episode of recurrent headaches, his past history was unremarkable except for a closed head injury a few years ago from playing soccer. He admitted to smoking 1 pack of cigarettes per day for the last 20 years. His family history was positive for headaches. His father would have bouts of headaches causing him to miss work.

On exam, I asked him to try and stop moving, as he was restless. His vital signs were normal and he was afebrile. His neck was soft and the neurological exam was unremarkable except for the miosis (small or constricted pupil) of his right eye and redness of the conjunctiva. Also, his right eye was tearing.

This presentation was consistent with cluster headaches, called that because the headaches occur in clusters over a few weeks, then go away, often for many months at a time. I immediately placed the patient on 100% oxygen via NRB at 15L/min. Within 5 minutes he reported the pain had subsided. I had him continue with the oxygen for a full 15 minutes to avoid the headache returning.

Prior to discharge from the ER, I gave the patient prescriptions for prednisone taper and verapamil to be taken daily as a preventative treatment. He was also given a prescription for Sumatriptan to take if the headache was to recur. I suggested he consider being a non-smoker as smoking is a risk for cluster headaches (in addition to all the other havoc smoking causes to the body).

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