Cluster headaches Flashcards
what is the definition of cluster headaches?
Cluster headache is considered one of the most painful conditions known. The clinical picture consists of unilateral headache attacks lasting 15 to 180 minutes, associated with autonomic symptoms secondary to parasympathetic hyperactivity and sympathetic hypo-activity. Some patients will develop chronic cluster headache and experience daily attacks without periods of remission. Pain is often localised to the unilateral orbital, supra-orbital, and/or temporal areas and can occur from once every other day to 8 times per day.
<3 hours
A. At least five headache attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated
C. Headache is accompanied by ipsilateral cranial autonomic features and/or a sense of restlessness or agitation
D. Attacks have a frequency from 1 every other day to 8 per day
E. Not attributed to another disorder
Episodic ≥ 2 cluster periods lasting 7 days to 1 year separated by pain free periods lasting ≥1 month
Chronic attacks occur for more than 1 year without remission or with remission lasting <1 month.
what is the epidemiology of cluster headaches?
Long diagnosis time - around 3 years
Multiple GPs normally seen
Male predominance
Between 20 and 40
what is the aetiology of cluster headaches?
The aetiology is not known. A history of head trauma, heavy cigarette smoking, and heavy alcohol intake are all associated with the disease, although no causal relationship has been found. Smoking cessation has no effect on the disease
what are the risk factors of cluster headaches?
Male Family history Head injury Smoking Drinking
what is the pathophysiology of cluster headaches?
The pathogenesis is complex and not understood completely. The three cardinal features of the disorder are:
Trigeminal distribution of the pain
Ipsilateral cranial autonomic symptoms
Circadian/circannual pattern of attacks.
There is a well-described physiologic reflex arc, the trigeminal autonomic 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 area known as 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. This results in increased firing of the parasympathetic fibres innervating facial structures, and causes 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.
what are the key presentations of cluster headaches?
Risk factors Repeated attacks of unilateral pain Excruciating pain Lacrimation, rhinorrhoea and partial horner's syndrome Agitation Nausea, vomiting Photophobia Migrainous aura
what are the signs of cluster headaches?
Lacrimation, rhinorrhoea and partial horner’s syndrome
Risk factors
what are the symptoms of cluster headaches?
Repeated attacks of unilateral pain Excruciating pain Agitation Nausea, vomiting Photophobia Migrainous aura
what are the first line and gold standard investigations for cluster headaches?
Brain MRI without and with IV contrast - normal in primary cluster headache; abnormal results might indicate secondary causes (e.g., tumour, cavernous sinus pathology)
ESR - normal in primary
Pituitary function tests - normal in primary cluster headache; abnormalities may suggest secondary causes resulting from a pituitary adenoma
what are the differential diagnoses for cluster headaches?
Migraine
paroxysmal hemicrania
SUNCT
how are cluster headaches managed?
Acute (no CV disease or hypertension):
SC sumatriptan (selective serotonin receptor agonist), oxygen, intranasal zolmitriptan, intranasal sumatriptan or oral zolmitriptan, intranasal lidocaine
Acute (with CV disease or hypertension):
Oxygen, intranasal lidocaine (local anaesthetic)
Long term use:
Verapamil, lithium, topiramate, gabapentin, melatonin
how are cluster headaches monitored?
All patients with suspected cluster headache should be seen by a neurologist, and all patients with atypical attacks or in whom first-line treatment is ineffective should be referred to a headache specialist
what are the complications of cluster headaches?
depression
what is the prognosis of cluster headaches?
Long-term prognosis is unclear. However, epidemiological studies have suggested that symptoms tend to improve with increasing age.
