Cluster Headache Flashcards
Define cluster headache.
Cluster headache is an attack of severe pain localised to the unilateral orbital, supra-orbital, and/or temporal areas that lasts from 15 minutes to 3 hours. It occurs from once every other day to 8 times per day.
How common is cluster headache?
- One of the few headaches which affect men predominantly (3:1)
- 8-10% of all headaches
- Onset 20-40yrs
- 10% have chronic form, 90% episodic form
What is the pathophysiology of cluster headache?
Associated with ANS symptoms secondary to PNS hyperactivity and SNS hypoactivity.
Trigemino-parasympathetic reflex arc → trigeminal pain and cranial autonomic features of cluster headache.
3 cardinal features of cluster headaches:
- trigeminal distribution of pain
- ipsilateral cranial autonomic symptoms
- circadian/circannual pattern of attacks
What are the triggers/risk factors for cluster headache?
- Alcohol (50-60%) - within 1hr of ingestion (migraines in contrast are triggered several hours later)
- Sleep e.g. daytime naps
- Volatile smells e.g. perfume and painr
- Warm temperatures
- Male sex
- FH
- Cigarette smoking
- Head injury
Where is the pain localised in cluster headache?
Pain is often localised to unilateral orbital, supra-orbital and/or temporal areas or maxillary region.
How do patients describe the pain in cluster headache?
- Excruciating - peaks within a few mins
- Worst ever experienced with women comparing it to childbirth
- Pain is boring, sharp, piercing, burning or pulsating
- Many complain of a constant pressing/burining background pain or “shadows” between attacks
Does the pain spread anywhere in cluster headache?
Usually strictly unilateral but some patinets report shifting between or during bouts of headaches but not during the attack itself.
What associated symptoms occur with cluster headaches? What distinguishes it from migraine?
Autonomic features accompanying pain include:
- ptosis and miosis (partial Horner’s syndrome)
- conjunctival injection,
- lacrimation,
- rhinorrhoea,
- nasal stuffiness,
- eyelid and facial swelling,
- aural fullness,
- facial sweating,
- and redness.
Most patients become very restless or agitated during an acute attack, unlike people with migraine who often report motion sensitivity during attacks.
How often do cluster headaches occur in patients who experience them?
- Can occur from once every other day to 8 times per day.
- Can show cyclical periodicity occurring at the same time of year or the same time of day.
- 90% have episodic cluster headaches e.g. attacks last 7 days to 1 year separated by remission periods lasting at least 1 month.
What is partial Horner’s syndrome?
Ptosis and miosis
What are the risk factors for cluster headache?
Male - 2-3:1 male to female ratio
FH - x14 risk
Head injury - no causative links established
Smoking - 85% are smokers but stopping doesn’t reduce frequency of cluster headache
Drinking alcohol
What symptoms need to be present to fulfil International Headache Society criteria for cluster headache?
At least one autonomic feature for diagnosis (although autonomic features are absent in 3% of patients)
Lacrimation is the most frequent symptom, followed by conjunctival injection, nasal congestion, rhinorrhoea, and partial Horner’s syndrome (ptosis and miosis).
What investigations should you do for cluster headaches?
- Examine for partial Horner’s syndrome/ipsilateral ptosis
Other:
- ESR - to exclude GCA in >50yr olds
- Pituitary function tests - if abnormal may suggest pituitary adenoma
- Brain CT/MRI - to eliminate secondary causes. Consider MRI pituitary
Should all be normal in cluster headache.
What are the differences between trigeminal neuralgia and cluster headache?
How do you diagnose cluster headache?
Purely clinical diagnosis - it is a primary headache syndrome
