Severe headache during chemotherapy for small-cell lung cancer

What happened, in summary

A 58-year-old man with a 30-year smoking history presented with chest pain, dry cough, breathlessness, and swelling of the neck and anterior chest wall. CT showed a 5 x 6 cm subcarinal and right hilar nodal mass, and fine-needle aspiration confirmed small-cell carcinoma. He began cisplatin and etoposide. Bilateral internal jugular vein thrombosis was also found, so low-molecular-weight heparin was started. Three days after the first cycle, he developed a severe whole-head pressure headache with photophobia, nausea, and vomiting. MRI, venography, cerebrospinal fluid testing, and pressure measurements did not identify brain metastasis, thrombosis, meningitis, or raised intracranial pressure. The headache did not respond to NSAIDs or tramadol and required intravenous morphine. The same debilitating episode returned after the second cycle, again requiring high-dose morphine. Because the pattern repeatedly followed cisplatin and etoposide, his chemotherapy was changed to carboplatin and irinotecan. He had no further post-chemotherapy headaches during subsequent cycles. At follow-up about four to five months after treatment began, he had completed five cycles, no longer had chest pain or cough, and had only slight shortness of breath on exertion. The regimen change allowed him to continue cancer treatment while substantially improving his quality of life.