In evaluating a patient with a severe unilateral periorbital headache and Horner-like symptoms, which diagnosis is most likely?

• A. Tension-type headache
• B. Cluster headache
• C. Migraine without aura
• D. Meningitis

Answer: (B)

Cluster headache is the pattern you’re seeing here. It’s a syndrome of severe, unilateral periorbital or retro-orbital pain that occurs in short, repetitive bursts, and it brings on autonomic symptoms on the same side of the face. The Horner-like signs—ptosis and miosis—are classic because the pain and autonomic symptoms reflect involvement of the trigeminal autonomic pathways with local sympathetic disturbance. The combination of an intensely painful, unilateral eye region with Horner-type features strongly points to cluster headache rather than other headache types.

Tension-type headaches are usually bilateral and pressing, without prominent autonomic signs. Migraines without aura can be unilateral but typically lack the pronounced, ipsilateral autonomic features and the frequent, clustered timing. Meningitis would present with systemic illness and meningeal symptoms like fever, neck stiffness, and altered mental status, not a focused periorbital pain with Horner signs.