Thanksgiving

I hope everyone has a lovely Thanksgiving. One of the things I am thankful for has to do with a patient of mine. This is an older gentleman with cancer who has been having intractable headaches. Every day when I see him, he's clutching his head in pain, feeling like his "eyes are going to pop out." He strikes me as the type of person who wouldn't complain about something trivial. Massive doses of narcotics (24mg PO dilaudid and 24mg IV dilaudid over one 24 hour period) were not relieving the pain. I tried really hard to figure out this headache. Was it a burst aneurysm (negative CT means we need an LP, he has some risk factors, but he's had this headache in the past and it didn't sound like a subarachnoid)? Is it an expanding subdural? Is it cluster? Is it a migraine? Or is it simply the cancer becoming intractable? Finally, after exploring the history, I got a sense it could be musculoskeletal. We tried cyclobenazeprine, a long-acting skeletal muscle relaxant. He was finally able to fall asleep. For that, I am thankful.