Cluster Headache
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Introduction

Cluster Headache –  aka – migranous neuralgia accounts for <1% of all headaches.
Cluster headache causes a unilateral pain that typically wakes the patient during the night, so called, because attacks occur in ‘clusters’ – e.g. many attacks in the space of a week, then no attacks for several months. The typical patient is male aged 30-40. Alcohol often precipitates attacks.
There is usually no visual disturbance and no vomiting.

Epidemiology and Aetiology

  • 10-50x less common than migraine
  • M:F – 5:1
  • Often disappear after the age of 55
  • Patients are often smokers with a high alcohol intake, although there are no proven aetiological factors, and no genetic links

Clinical features

  • Episodic, Intense, unilateral pain – usually around one eye, increasing in intensity over 30-60 minutes, and then lasting anywhere between 30-90 minutes.
    • Typically, episodes occur grouped together – e.g. several in one week, then nor more attack for several months.
    • Can have 2 or more attack in one day
    • In some patients it is chronic, and there are no periods without attacks
  • Usually occurs in the early hours of the morning
  • Unilateral lacrimation, rhinorrhoea (runny nose) and post-nasal drip. Eye may be become bloodshot, and the lid may swell.
  • Miosis and ptosis can occur, and in 5% of cases this can be permanent.
  • Vomiting is unusual
  • Feeling of congestion of the sinuses unilaterally
  • Transient ipsilateral Horner’s Syndrome

Diagnosis

  • At least 5 attacks
  • Sudden onset, unilateral headache
    • Orbital or retro-orbital
    • Lasting 15min – 3 hours
  • At least 2 of
    • Associated rhinorrhoea
    • Eyelid oedema
    • Facial swelling
    • Ipsilateral (same side) conjunctival redness or excessive lacrimation (tears)
    • Forehead or facial swelling or flushing
    • Miosis or ptosis
  • Occur between once every 2 days and 8 times daily

If headache is new – consider CT – sudden onset headaches are often more clinically significant than gradual onset and chronic headaches

Pathology

On fMRI scans there is often changes in the grey matter of the hypothalamus. Some believe that it is caused by superficial temporal artery overactivity in response to 5-HT.
Cluster headache MRI
Cluster headache MRI – specifically a type of scan called Voxel-based morphometry – which is highlighting abnormal hypothalamic activity. This file is taken from wikimedia commons and is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

Treatment

Analgesia is often not very useful.
Acute attack:
  • 100% oxygen – use a non-rebreathing mask at 7-15L for around 15 minutes
  • Subcutaneous sumatriptan – 6mg at onset of attack
Other acute therapies, such as those for migraine are not thought to be effective
Prophylaxis
Once a “cluster” has begin, instigate prophylactic therapy.
  • Verapamil80-120mg every 8 hours
  • Corticosteroids – short courses – consider prednisolone 50mg/day for 10 days, followed by a sort taper before cessation
  • Methysergide – 4-10mg/day for up to 3 months
  • Lithium
  • Sodium valproate

References

  • Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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