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Dr. C.: The patient is a forty-seven-year-old telephone company supervisor. For the past seven years he has had attacks which begin with pressure and pain over the right eye. This is accompanied by simultaneous right parasternal chest pain and sometimes by pain in his left arm. The syndrome is so distressing that he is "transfixed" by it. He has difficulty in talking and in concentrating. He may have five or six attacks in an hour, or attacks occurring once an hour for several days.Because he has difficulty in describing the attacks, their duration and associated symptoms, his physician has asked him to keep a diary. It indicates that he had a four-day episode December 20 through 23, 1976, and another December 28 through 30. He had similar attacks March 26-28 and April 3-4, inclusive, in 1977. He may go five or six months without a group of attacks. During an attack his right eye has no subjective congestion or lacrimation. He has no nasal congestion, or photophobia, but he does wear tinted glasses, dislikes fluorescent lights and driving in the sun. The attacks do not produce nausea but they make him anorexic and irritable.His past history reveals that he is a recovered alcoholic, is known to have asthma, and has had two or three episodes of pneumonia. He states that he is not in good physical condition, but physical examination was normal and he is well muscled. He plays ball with his three young sons, and a recent electrocardiogram and cardiac stress test were normal. Neurological examination was also normal. For treatment, Bellergal has been tried without benefit. Cafergot in combination with Fiorinal will modify an attack if taken early.Dr. Sp.: To patient. Would you describe how an attack comes on and what it feels like?PATIENT: A gripping feeling over my right eye signals an attack. I don't want to take anything for it, but my wife urges me to take Cafergot, and if I do, sometimes that will ward it off. If I take nothing, then a burning headache comes over my right eye, and at the same time a tight feeling in my right chest which turns into pain. Occasionally I have a tingling sensation in my left arm.Dr. Sp.: Does anything else bring on the chest pain, physical exertion, like playing ball with the kids?

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