Case Study: 24-Year-Old Male with Unilateral, Cough-Induced Headache and Facial Pain

Case at a Glance

A 24-year-old male presented with a severe, right-sided frontal headache, sharply exacerbated by coughing, and associated with ipsilateral maxillary pressure. The symptoms were refractory to empirical treatments for sinusitis, prompting a broader differential diagnosis.

Patient's Story

The patient, a 24-year-old male, reported a distressing history of a right-sided frontal headache. He described that any Valsalva-like maneuver, particularly coughing, would trigger an excruciating, lancinating pain he rated as 10/10 in severity. This spike was brief but debilitating and located exclusively on the right side of his head. He also occasionally experienced a sensation of pressure over his right maxillary sinus. The patient expressed significant anxiety and frustration due to the severity of his symptoms and administrative delays in accessing specialist care and diagnostic imaging through his insurance.

Initial Assessment

The patient's initial presentation, with unilateral headache and facial pressure, suggested a possible diagnosis of acute rhinosinusitis. Based on this working diagnosis, he had undergone several empirical treatments prior to seeking further consultation. He had completed a 5-day course of amoxicillin and a 6-day course of prednisone, along with using a neti pot for saline irrigation and fluticasone nasal spray. The complete lack of response to these therapies suggested the initial diagnosis was likely incorrect.

The Diagnostic Journey

The failure of treatments aimed at infectious or inflammatory sinusitis prompted a re-evaluation of the case. The key clinical features were the strictly unilateral nature of the pain and the specific trigger—coughing—that caused a dramatic, sharp increase in pain intensity. This clinical picture shifted the differential diagnosis away from sinusitis and towards other etiologies. A primary cough headache was considered, though these are often bilateral. Given the facial location and the sharp, shock-like character of the pain, Trigeminal Neuralgia (TN) was raised as a significant possibility, potentially being triggered by the pressure changes associated with a cough.

Final Diagnosis

A definitive diagnosis is pending further neurological and otolaryngological evaluation, including advanced imaging. Based on the clinical presentation, the leading differential diagnoses are:

1. Trigeminal Neuralgia (TN): The lancinating, unilateral pain is highly characteristic.
2. Secondary Cough Headache: A cough-induced headache warrants imaging (CT/MRI) to rule out an underlying structural cause, such as a Chiari malformation or other intracranial pathology.
3. Atypical Sinus Disease: While unlikely given the failure of treatment, a complex or obstructive sinus issue cannot be entirely ruled out without imaging.

Treatment Plan

The recommended plan is contingent on a definitive diagnosis. The immediate steps should include:

1. Urgent Neurological Consultation: To formally assess for a primary headache disorder or neuralgia.
2. Diagnostic Imaging: An urgent CT scan or, preferably, an MRI of the brain and sinuses is critical to rule out structural lesions or nerve compression.
3. Pain Management: While awaiting a diagnosis, a trial of a neuropathic pain agent, such as carbamazepine or gabapentin, could be considered under medical supervision to manage symptoms if Trigeminal Neuralgia is highly suspected.

Outcome and Follow-up

The patient was in the process of seeking a diagnosis at the time of this report. The outcome is unknown. He was strongly advised to pursue an urgent evaluation with a primary care physician to facilitate referrals to neurology and for necessary imaging, despite the logistical challenges he faced. Close follow-up is essential for accurate diagnosis and effective management.