cluster headache

Question 1

definition of cluster headache

Answer 1

considered one of the most painful conditions known to humanity.

Question 2

RF of cluster headache

Answer 2

male

FH

head injury

cigarette

heavy drinking

aetiology unknown

Question 3

pathogenesis of cluster headache

Answer 3

complex

cardinal features - trigeminal distribution of pain, ipsilateral cranial autonomic symptoms, circadian/circannual pattern of attacks

the trigemino-parasympathetic reflex, that is thought to potentiate the trigeminal pain and cranial autonomic features of cluster headache.

Nociceptive information from pain-sensitive structures in the face, and particularly the dura mater and cerebral blood vessels, is carried to the brainstem via the trigeminal nerve.

Within the brainstem, these trigeminal fibres synapse in the trigeminocervical complex (TCC).

Information is then sent to the hypothalamus, thalamus, and cortex via the pain-processing pathways.

Afferent trigeminal signals arriving at the TCC activate the cranial parasympathetic system = increased firing of the parasympathetic fibres innervating facial structures = the autonomic features seen in an attack.

Neurotransmitters released at these parasympathetic nerve endings cause further irritation of the trigeminal sensory nerve endings, and this potentiates the reflex arc further.

The timing of cluster headaches and the agitation associated with attacks have led to the belief that the hypothalamus must play a role in the pathophysiology of cluster headache.

Question 4

epidemiology of cluster headache

Answer 4

male

any age

Question 5

sx of cluster

Answer 5

rapid onset of excruciating pain around 1 eye

eye may become watery (lacrimation) and bloodshot

lid swelling

facial flushing

rhinorrhoea

miosis +- ptosis (20% attacks)

pain unilateral - almost always affects the same side

lasts 15-180mins, once/twice daily

nocturnal

last 4-12wks followed by pain free periods of mo/1-2yrs

sometimes chronic, not episodic

Question 6

Ix for cluster headache

Answer 6

brain CT/MRI - normal in primary cluster headache; abnormal results might indicate secondary causes (e.g., tumour, cavernous sinus pathology)

ESR - to exclude giant cell arteritis - normal in cluster

pit function tests - normal in primary cluster headache; abnormalities may suggest secondary causes resulting from a pituitary adenoma

Question 7

acute mx of cluster headache

Answer 7

100% oxygen 12-15 L non-rebreather face mask

subcut triptan - take 1 dose and if has some effect can take another after 1 hour - max 2 doses a day!!
can do intranasal- up to 2 doses

Question 8

prophylaxis of cluster headache

Answer 8

verapamil
assess for triggers - smoking, diet, stress, anxiety, mood disorders

Question 9

other diseases in spectrum of cluster headache

Answer 9

paroxysmal hemicrania

short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT)

Question 10

complications of cluster headache

Answer 10

QOL
anxiety and depression
suicide

Question 11

px of cluster headache

Answer 11

lifelong - but can be less freq bouts