CLUSTER HEADACHE

CLUSTER HEADACHE

Description:

Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15-180 minutes and occurring from once every other day to 8 times a day. The attacks are associated with one or more of the following, all of which are ipsilateral: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis, eyelid oedema. Most patients are restless or agitated during an attack.

Other Name

1. Suicide headache" because of its severity
2. Alarm clock" headache
3. Red Migraine
4. Cilliary neuralgia
5. Autonomic faciocephalalgia

Epidemiology

• Rarely
• There was ± 0.4% pd general population
• Ratio of ♂: ♀ = 5:1
• Can occur in children and adults (rare before 10 years) usually begins in the second or fourth decade
• 90% and 10% episodic cluster chronic (cluster period lasts for more than one year without remission or remission lasts less than 14 days).

IHS CLASSIFICATION

Cluster headache

Episodic type (90%)

Chronic type (10%)

(Cluster period lasts for more than one year without 

remission or remission lasts less than 14 days)

Clinical Manifestations

• Unilateral orbital / temporal severe pain
• Sharp stabbing
• Pain is usually located around the eye radiating to the temple, forehead, cheek nose, or gums
• Piercing, stabbing pain
• Rapid onset (5 – 15 min)
• Duration of 30 to 180 minutes
• 1 to 8 attacks per day
• Frequently at night
• Majority of sufferers are male

Cluster headache

Other Clinical Manifestations

•      Other manifestations include

–     Swelling around the eye

–     Lacrimation

–     Facial flushing or pallor

–     Rhinitis

–     Constriction of the pupil

•      “Migrainous” symptoms: nausea,

            photophobia, phonophobia, aura

•      Autonomic features

CIRCANNUAL PERIODICITY
Cluster Periods

Kudrow L. Cephalalgia. 1987.

Waldenlind E. Cluster Headache and Related Conditions. 1999

CIRCADIAN PERIODICITY
Cluster Attacks

•      1 to 3 attacks daily (up to 8 attacks/day)

•      Peak time periods

 

REM sleep;

Obstructive sleep apnea

Chervin RD et al. Neurology. 2001, Trucco M, Waldenlind E. Cephalalgia. 1993.

  

Characteristics of Common
Headache Syndromes

	Migraine	Tension	Cluster
Location	Unilateral 60-70% Bifrontal in 30%	Bilateral	Always unilateral, usually periorbital or temporal
Description	Gradual onset, crescendo pattern, pulsating, moderate or severe intensity, aggravated by routine physical activity	Pressure or tightness which waxes and wanes	Pain begins quickly, reaches crescendo within minutes; pain is deep, continuous, excruciating, and explosive in quality

Characteristics of Common
Headache Syndromes

	Migraine	Tension	Cluster
Patient Appearance	Mostly female Patient prefers to rest in a dark, quiet room	Mostly female Patient may remain active or may need to rest	Mostly men Patient remains active such as: restlessness, pacing, rocking back and forth. They avoid lying down.
Duration	4 to 72 hours	Variable Minutes to weeks	30 minutes to 3 hours
Associated Symptoms	Nausea, vomiting, photophobia, phonophobia, and possible aura	Scalp, neck and shoulder muscle pain. Insomnia Fatigue Irritability	Ipsilateral lacrimation, congestion, rhinorrhea, pallor, diaphoresis

Differential Diagnosis

PATHOGENESIS OF PAIN:
AUTONOMIC SIGNS

Diagnosis

• Diagnosis based on history
• Headache diary
• CT scan, MRI, or MRA issued a dx. aneurysm, tumor, or infection

Diagnostic Studies (cont’)

•      History: Questions to ask

–     Character of pain

–     Mode of onset

–     Mode of offset

–     Time of onset

–     Relieving factors

–     Aggravating factors

–     Presipitating factors

Treatment of Acute Cluster Headache

Drug	Dosage and route	Reported Adverse effects
Oxygen	7 L per minute for 15 minutes via face mask	None
Sumatriptan	6 mg subcutaneously; may repeat in 24 hours 20 mg nasal spray	Local skin reactions, fatigue, nausea, vomiting, dizziness, chest symptoms, throat symptoms, burning sensations, paresthesias None
Intranasal       dihydroergotamine	0.5 mg nasal spray bilaterally	None

OXYGEN

•      100% O2 : 7 – 10 liters / min for 15 to 20 minutes

•      Efficacy 70% at 15 minutes

•      Most effective when headache is at maximum intensity

•      Main limitation is lack of accessibility

            and inconvenience

THERAPY O2