The symptoms: The man, a fighter pilot in the Indian Air Force, went to a civilian neurologist after having persistent headaches for 18 months. The headaches would occur approximately two to three times per month, starting in the late afternoon and lasting up to three days. Sleep did not improve his symptoms.
Sometimes, the pain was so intense that the man was unable to take part in scheduled flights. If he flew anyway during an episode, his headache would be even worse the next day.
When asked about his medical history, the pilot recalled no recent ailments or conditions that could cause recurring headaches, such as inflammation and congestion of the sinuses (sinusitis). He had no family history of chronic headaches or migraine, a neurological disease that frequently causes moderate to severe headache, among other symptoms. Nor did he experience nausea, vomiting or visual anomalies called "auras," which often accompany or precede migraines.
The diagnosis: The military doctors reviewed the pilot's case and examined him. All of his test results were in the normal range, and a CT scan showed no brain abnormalities. They ordered a nasal endoscopy — an exam that uses a camera to examine the nasal cavity and sinuses — and found that the patient had a deviated septum. However, the deviation was so minor that they ruled it out as a possible cause of his pain.
Indian Air Force (IAF) fighter jets photographed in 2019. The patient's headaches were sometimes so bad that they stopped him from conducting scheduled flights. (Image credit: Abhishek Singh via Getty Images)
The treatment: The pilot was given the migraine medicine sumatriptan, to be taken at the first sign of pain, and aspirin, to be taken during headaches. He was allowed to continue flying under restricted conditions, and he had to report to a military neurologist for monthly reviews over the next three months.
Over three days, doctors conducted in-depth interviews with the pilot, focusing on the first appearance of his symptoms and the circumstances leading up to his headaches. They were puzzled by certain details: His lack of nausea, vomiting and auras, and the fact that he got no relief through sleep. These facts raised questions about the migraine diagnosis.
"At that point the officer did not connect the cessation of headaches with the use of the new helmet," the doctors reported. "Reviewing the case in its entirety, the diagnosis of migraine or vascular headache was found to be incorrect; instead the individual was suffering from external compression headache due to an ill fitting helmet."
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What makes the case unique: When the military doctors scoured peer-reviewed studies, they found no reports of similar instances of compression headache "in any of the Air Forces of the world," they wrote in the report.
For more intriguing medical cases, check out our Diagnostic Dilemma archives.
Can you guess the diagnosis in these strange medical cases? Find out with our diagnostic dilemma quiz!
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