Cluster Headache

EM

Cluster headache

not Common

Cluster headache

is an infrequent neurological disorder characterized by recurrent, severe unilateral headaches, typically around the eye

• Men are more commonly affected
• Occurs in people younger than 30
• Often has nocturnal onset

Pathophysiology

• The cause is unknown, does have some genetic association, and is linked to smoking, some theoretical association with hypothalamic activation of the trigeminal nerve
• Most common associated trigger is seasonality often occurring in spring and autumn.

Signs and symptoms

• Cluster headache is always unilateral, or one-sided

• The pain of a cluster headache is generally very intense and severe and is often described as having a burning or piercing quality

• The pain is retroorbital/periorbital. It may radiate to the forehead, temple, nose, cheek, or upper gum on the affected side.

• the pain of a cluster headache lasts a short time, generally 30 to 90 minutes. It may, however, last from 15 minutes to three hours.

• Most sufferers get one to three headaches per day during a cluster period. They occur very regularly, generally at the same time each day, hence called “alarm clock headaches”

• Need to be accompanied by autonomic symptoms such as: dropping eyelid, pupil constriction, conjunctival injection, tearing rhinorrhea and rarely facial blushing, swelling and sweating.

• Cluster headaches are typically associated with nausea and vomiting

• cluster headaches occurring in two or more cluster periods, lasting from 7 to 365 days with a pain-free remission of one month or longer between the headache attacks, may be classified as episodic. If headache attacks occur for more than a year without pain-free remission of at least one month, the condition is classified as chronic

Treatment

Acute treatment

• 100% oxygen at 10–12 L/min for 15–20 min

• sumatriptan- Subcutaneous(6 mg) or intranasal

• Preventive treatment

• Verapamil, methysergide, prednisolone, topiramate, lithium

• -Neurostimulation therapy — deep brain stimulation or occipital nerve stimulation

IM

Cluster Headache

Clinical Features:

1. Recurrent episodes of severe unilateral headache, around the eye & temples (trigeminal distribution)
2. Sudden onset, very very severe headache
3. Accompanied by same side lacrimation, eye redness & swelling, nasal congestion, runny nose & Horner’s syndrome (ptosis + meiosis + anhidrosis) (may be cause due pancoast tumor + Horner’s syndrome)
4. Each episode lasts for few minutes to hours
5. Attacks occur daily for few weeks, then stop, then recur after a variable period (clusters)
6. No aura
7. Occur at the same time each year (e.g., spring, winter)

Triggering Factors:

Many of them same as migraine

Etiology:

Unknown

Where is the problem?:

Hypothalamus, which somehow affects the trigeminal nerve

Diagnosis:

Based on symptoms

Differential Diagnosis:

Migraine, Trigeminal neuralgia, Temporal arteritis

Treatment

A) Acute Attack:

• 100% O2 at high flow rate (15L/min) for about 20 min
• Triptans (intranasal or subcutaneous sumatriptan). Oral tabs not very effective)

B) Maintenance Prophylactic Treatment (if attacks are frequent)

• Verapamil (first choice) (migraine) CCBs X
• Lithium tablets

Rapid Fire Questions on Cluster Headache

1. Location of cluster headache? around the eye
2. Where is the pathology? hypothalamus
3. Clinical features? Congestion, swelling, tearing
4. What is Horner’s syndrome? Ptosis, Myosis, Anhidrosis
5. Any triggers? same
6. Acute treatment? O2 100% 15L
7. Chronic treatment? Verapmil, Lithum tablets
8. Differential diagnosis? Temporal Artiritis, Migraine, trigeminal neuralgia
9. Any aura? no aura

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FM

Cluster Headache

• Very Severe
• Frequent

Associated with parasympathetic autonomic features:

• Injected sclera
• Lacrimation
• Rhinorrhea
• Facial sweating
• Eyelid swelling

Treatment

Cluster Headache

Acute Treatment:

• Subcutaneous sumatriptan
• Oxygen inhalation.

Prevention:

• Verapamil – corticosteroids – lithium - Methysergide.