Man referred with headache and unilateral ptosis

A 73-year-old man was referred to the neuro-ophthalmology service for evaluation of headache with associated right upper eyelid ptosis. Two weeks before presentation, he noted the onset of right-sided periorbital headache, which intensified upon lying down. The headache was intermittent but worsened over the subsequent days, and this corresponded with drooping of his right upper eyelid. He went to his local emergency department, where a non-contrast CT scan of his head was unremarkable. The following day he saw an ophthalmologist, and he was presumptively diagnosed with cluster headache.He followed up with his primary ophthalmologist who recommended a thorough neuro-ophthalmological exam. Upon presentation, he described vague changes in his vision, as though his brain had “difficulty making images work,” but he denied frank double vision. He did not experience loss of visual acuity, changes in color vision or pain with eye movement. He had no recent trauma. He felt as though the ptosis worsened over the course of each day. His ocular history was remarkable only for presbyopia and moderate cataracts, and he had a complete eye exam 2 months prior. His medical history was significant for benign prostatic hypertrophy, for which he took tamsulosin. His family and social histories were non-contributory. His review of systems was positive for general malaise and body aches. He denied scalp tenderness, jaw claudication, recent fevers, neck pain, cough or difficulty breathing.