3.3.2.2 Chronic SUNA

## Patient Identification
- **Name:** J.A.M.
- **Age:** 38 years
- **Gender:** Male
- **Profession:** Civil Engineer
- **Marital Status:** Single
- **Origin:** Santos, SP

## Chief Complaint
"For over a year, I've had headaches on the left side that occur several times a day, every day, without stopping."

## History of Present Illness
A male patient reports a headache condition that began approximately 18 months ago, characterized by episodes of unilateral left-sided pain, with severe to very severe intensity (8-10/10 on the visual analog scale), lasting between 10 seconds to 4 minutes.

The episodes have been continuous for more than 12 months, without remission periods longer than 48 hours. The average frequency is 25-40 episodes per day, with irregular distribution over 24 hours, including frequent nocturnal awakenings (3-5 times/night).

The pain is described as "stabbing" or "intense piercing" in the left temporal and orbital region, occasionally radiating to the ipsilateral frontal and upper maxillary region. Occasionally, he reports a sensation of "deep burning" in the same area.

During the episodes, he consistently presents with:
- Abundant tearing on the left
- Intense unilateral nasal congestion
- Profuse clear rhinorrhea
- Slight but noticeable ptosis
- Slight miosis on the left
- Ipsilateral conjunctival hyperemia
- Sensation of aural fullness

The patient has developed restless behavior during episodes, with a need to walk or press the temporal region. He denies photophobia, phonophobia, nausea, or vomiting. He does not identify specific triggers but notes a slight increase in frequency during periods of higher work stress.

## Past Medical History
- Allergic rhinitis since adolescence
- Episode of tension-type headache 3 years ago (treated with simple analgesics)
- Denies head trauma, central nervous system infections
- Denies previous surgeries or other neurological comorbidities
- Previous irregular use of common analgesics without satisfactory response

## Family History
- Paternal grandfather with "severe headaches" (poorly detailed history)
- Mother with sporadic migraine
- Denies consanguinity or other primary headaches in the family

## Lifestyle Habits
- Smoker: 1 pack/day for 15 years
- Moderate social alcohol consumption (weekends)
- Sedentary due to limitations imposed by headache
- Irregular sleep pattern (due to nocturnal awakenings)
- Frequent use of dipyrone and paracetamol without efficacy

## Physical Examination
### General Examination
- General condition regular, emaciated, colored, hydrated
- BP: 140/90 mmHg, HR: 88 bpm, Temp: 36.8°C
- Weight: 72kg, Height: 1.78m, BMI: 22.7 kg/m²
- Appearance of fatigue and anxiety

### Neurological Examination
- Patient conscious, oriented, cooperative but anxious
- Higher cortical functions preserved
- **Cranial Nerves:**
- Slight anisocoria (left pupil smaller) - more evident after episodes
- Subtle, intermittent left ptosis
- Other cranial nerves without alterations
- Muscle strength: grade V in all segments
- Symmetrical and normoactive tendon reflexes
- Coordination and balance preserved
- Normal gait
- Meningeal signs absent
- **Fundoscopy:** no papilledema, normal arteriovenous ratio

### Headache Examination (during interictal period)
- Palpation of the left temporal region slightly painful
- Discrete residual autonomic signs (mild conjunctival hyperemia)
- Free cervical movement
- Trigger points absent

## Complementary Exams
### Brain MRI with Contrast
- Normal signal and morphology of brain parenchyma
- Absence of expansive, vascular, or inflammatory lesions
- Clear basal cisterns
- Normal ventricular system caliber
- Preserved posterior fossa structures
- **Special attention:** No alterations in the posterior hypothalamic region

### Cranial Angio-MRI
- Anterior and posterior circulation without alterations
- Absence of vascular malformations or aneurysms
- Patent venous sinuses

### Complete Laboratory
- Hemogram: Hb 13.2 g/dL, Leukocytes 7,800/mm³, Platelets 280,000/mm³
- ESR: 15 mm/h, CRP: 0.8 mg/L
- Glucose: 92 mg/dL
- Normal renal and hepatic function
- Electrolytes without alterations

### Polysomnography
- Sleep fragmentation with multiple awakenings
- Reduced sleep efficiency (65%)
- Absence of sleep respiratory disorders