Cluster headaches

Question 1

What is a cluster headache?

Answer 1

Recurrent severe headaches on one side of the head (typically around the eye)

Question 2

Describe the pathology in a cluster headache (what happens and the consequences)

Answer 2

One-sided headache in ophthalmic nerve distribution with autonomic symptomology.

Sequence of events lead to cavernous sinus inflammation with reduced venous flow. This leads to injury of internal carotid artery sympathetic fibres

Question 3

What are the 2 types of cluster headaches?

Answer 3

EPISODIC- daily episodes over 6-12 weeks, followed by a remission period of up to 12 months

CHRONIC- episodes without a substantial remission period

Question 4

What is the cause of cluster headaches?

Answer 4

Unknown- may be superficial temporal artery smooth muscle hyperreactivity to 5HT. There is also hypothalamic grey matter abnormalities.

Question 5

Describe the epidemiology of cluster headaches

Question 6

What do they mean by cluster? Describe the pattern

Answer 6

Clusters refers to the pattern of the headaches with EACH cluster lasting a couple of weeks (4-12wks) and the clusters themselves typically occur once a year (same time each year).

The interval between bouts of headaches tends to be the same and onset 1-2 hours after falling asleep.

Question 7

What are some risk factors for cluster headaches?

Answer 7

• Being male (^ risk 5:1)
• Onset at any age
• Smoking/ tobacco use
• Alcohol drinker
• Patients who are under a lot of stress
• Allergic rhinitis

Question 8

What are the symptoms of cluster headaches?

Answer 8

• Rapid excruciating pain 1-2 times a day, episodes lasting 15mins- 2 hours.
• Clusters typically last 4-12 weeks
• Intense stabbing pain unilateral (every time) around one eye- in the supraorbital/ orbital/ temporal region. Always affects the same side.
• Eye may become watery, bloodshot (hyperemia), with lid swelling, lacrimation
• Facial flushing
• Nasal stuffiness

Question 9

What are the signs you might see O/E?

Answer 9

• miosis, ptosis (partial horner’s)
• Patient restless and agitated

Question 10

How would you diagnose cluster headaches?

Answer 10

Diagnosis:

• CT/MRI- to exclude extra cranial/ space occupying lesions

Criteria-

• 5 unilateral attacks in the eye area; 1-8 episode daily
• Headaches must have one or more accompanying autonomic syndrome to be classified as a cluster headache

Question 11

What is the management for cluster headaches?

Answer 11

Acute-

“Keep calm, carry oxygen”… give 100% O2 for 15 mins and SC sumatriptan on onset (or zolmitriptan nasal spray)

For prophylaxis, verapamil (if episodic attacks> 2 months/ chronic cluster headaches).

Glucocorticoids can also be used (prednisolone)- acts as a supportive/ tapering dose with the verapamil.

If severe and extremely chronic, consider surgery block greater occipital nerve, percutaneous radiofrequency ablation of pterygopalatine ganglion etc.

Question 12

What are the risk factors for cluster headaches?

Answer 12

(they often have a trigger)

• Smoking/ tobacco use
• Alcohol drinker
• Patients who are under a lot of stress
• Allergic rhinitis