Cluster headache (migrainous neuralgia)

Question 1

Triad

Answer 1

retro - orbital headache + rhinorrhoea + lacrimation

Question 2

Clinical features

Answer 2

Site: over or about one eye; always same side

Radiation: frontal and temporal regions

Quality: severe

Frequency: one every other day and 8 per day for more than half the time

Duration: 15 minutes to 180 minutes (average 30 minutes); the clusters last 4–6 weeks (can last months)

Onset: suddenly during night (usually), same time about 2–3 hours after falling asleep; the ‘alarm clock’ headache (e.g. 2–4 am)

Offset: spontaneous

Aggravating factors: alcohol (during cluster)

Relieving factors: drugs

Associated features:

family history; rhinorrhoea and/or congestion, ipsilateral nose; lacrimation; flushing and/or sweating of forehead and cheek; redness of ipsilateral eye; eyelid oedema; miosis and/or ptosis; sensation of fullness in ear; a sense of restlessness or agitation

Question 3

Characteristics

Answer 3

Occurs in paroxysmal clusters of unilateral headache

Typically occur nightly, usually early a.m.

A hallmark is the pronounced cyclical nature of the attacks.

Occurs typically in males (6:1 ratio).

Another feature is ptosis, lacrimation and rhinorrhoea on the side of the pain.

Question 4

Acute episode Ry

Answer 4

Administer sumatriptan – 6 mg subcutaneously, is the most effective treatment due to its rapid effect.

Consider oxygen 100% via a mask at 15 L/min for 10 to 20 minutes as this helps some people.

Standard simple analgesics are not effective.

Oral triptans and ergotamine are not effective.

Avoid alcohol completely during cluster episodes.

Question 5

Preventive treatment

Answer 5

Verapamil hydrochloride –

• 80 mg 3 TDS, increasing by 80 mg each 10 days to a maximum daily dose of 960 mg,
• with a baseline ECG and ECG with each increase in dose.
• Withdraw verapamil once the cluster has resolved.

Prednisone –

• 1 mg/kg up to 80 mg for 4 days,
• tapering the dose over 2 to 3 weeks is a well-accepted short-term preventive approach.
• Started with the verapamil.

Others:

• methysergide 2 mg (o) tds
• pizotifen
• indomethacin trial (helps confirm diagnosis)
• sodium valproate

If not controlled by the above treatments, request non-acute neurology assessment.