The patient, a 51-year-old male, presented with a 10-month history of a new headache, without any previous history of headache and in particular no history of headache with alcohol consumption.

The headaches began in January and he was seen in November. They had commenced one morning at work with a bout of coughing. They felt as a pressure wave that would radiate from the back of the head to the front on both sides. There was a severe, tight sensation for two to three minutes followed by a less severe pain for about an hour.

There was no nausea, photophobia, phonophobia, or osmophobia with these headaches. There was no visual disturbance, including blurring and no migrainous aura. He could walk afterward without discomfort although he was inclined not to do so.

There were no cranial autonomic symptoms, no dizziness, vertigo, or premonitory symptoms.

The headache could also be triggered by sneezing, lifting, and stooping. There was no effect of sexual excitement or of orgasm.

He was on no medications when he was seen.

He took no treatment for headache. He was taking a statin for hypercholesterolemia.

He had been treated with ibuprofen 800 mg and naproxen 440 mg and neither was helpful. He had tried sumatriptan 100 mg, rizatriptan 10 mg, and eletriptan 40 mg each without useful effect. He had an 8-week course of amitriptyline 50 mg nightly that was not helpful and made him drowsy with a dry mouth. He had been treated with topiramate 50 mg daily that was not useful and produced marked cognitive side effects that he could not tolerate. He had seen a chiropractor and osteopath and had acupuncture, none of which helped. He had a course of cognitive behavioral therapy that was not useful.

His past history was otherwise unremarkable.

There was no family history of headache, although he had not specifically asked his parents who were both dead.

He was a nonsmoker who took alcohol perhaps twice a week without headache and cannabis weekly. The cannabis did not prevent the headache onset.

On examination he was well, in no distress and weighed 76 Kg. Neck movements were full and the neck was painless to palpation, including the region around the greater occipital nerves. In the cranial nerves, the fields were full and the fundi normal. Color visual was normal as was opticokinetic nystagmus. The eye movements were full with normal full pursuits and normal saccadic movements. There was no trigeminal or cervical sensory change. There was no facial asymmetry. Palate elevation and tongue movements were normal. There was no wasting or abnormal movements. Tone and power were equal and normal, and the reflexes symmetrical and normal with down-going toes. Gait and coordination were normal.