Cluster Headhaches

Question 1

give a typical presentation of a cluster headache?

Answer 1

INTERMITTENT Unilateral, behind eye, cyclical pattern (intense, sharp and penetrating) + pace around + watery eyes/facial flushing/ nasal cong (ANS symp) - headaches come on multiple times in a few weeks and resolve spontaneously then may occur again after a few months/yr

Question 2

define cluster headaches?

Answer 2

Cluster headache is considered one of the most painful conditions known to humanity.

pain localised to the unilateral orbital, supra-orbital, and/or temporal areas; lasts from 15 minutes to 3 hours

Attacks occur at the same time period for several weeks (the cluster period); accompanied by ipsilateral autonomic signs.

Question 3

what are the three cardinal features of cluster headaches?

Answer 3

Trigeminal distribution of the pain

Ipsilateral cranial autonomic symptoms

Circadian/circannual pattern of attacks.

Question 4

what are the risk factors for cluster headaches ?

Answer 4

male

cigarette smoking

head injury

heavy drinking

family history

Question 5

summarise the epidemiology of cluster headaches?

Answer 5

More common in MEN

Usually occurs between 20-40 yrs

Patients usually smokers with high alcohol intake

Question 6

what are the 2 types of cluster headaches?

Answer 6

Episodic - occurring in periods lasting 7 days - 1 year, separated by pain-free periods lasting a month or longer.

Chronic - occurring for 1 year without remissions or with short-lived remissions of less than a month. Can arise de novo or arise from episodic cluster headaches.

Question 7

what is the pattern of occurence of cluster headaches?

Answer 7

• Headaches occur in clusters lasting 4-12 weeks
• These occur once every year or once every 2 years, and tends to occur at the same time each year
• Headaches typically occur at night, 1-2 hours after falling asleep
• The interval between bouts tends to be the same
• 10% with episodic cluster headaches go on to develop chronic cluster headaches

Question 8

describe the symptoms of cluster headaches?

Answer 8

Pain comes on rapidly over around 10 mins

Pain is intense, sharp and penetrating

Pain is centred around the eye, temple or forehead

Pain is unilateral – always affects the same side

Pain typically lasts around 45-90 mins (range: 15 mins - 3 hours)

Pain occurs once or twice daily

Associated autonomic features:

• Ipsilateral lacrimation
• Rhinorrhoea
• Nasal congestion
• Eye lid swelling
• Facial swelling and flushing
• Flushing
• Conjunctival injection
• Partial Horner’s syndrome (constricted pupil + drooping eyelid)

Patients find it difficult to stay still and will pace around, occasionally banging their heads on things

Question 9

what are the associated autonomic features of cluster headaches?

Answer 9

Ipsilateral lacrimation

Rhinorrhoea

Nasal congestion

Eye lid swelling

Facial swelling and flushing

Flushing

Conjunctival injection

Partial Horner’s syndrome (constricted pupil + drooping eyelid)

Question 10

what are the possible triggers of cluster headaches?

Answer 10

ALCOHOL - major precipitant

Exercise and solvents

Sleep disruption

Question 11

what are the appropriate investigations for cluster headahces?

Answer 11

CLINICAL diagnosis based on history – International Classification of Headache Disorders (ICHD) - refer to neurologist for confirmation

Neurological examination may be useful

Imagine e.g. CT to exclude other causes

ESR to exclude giant cell arteritis

Blood tests for pituitary function (e.g. TFT, LH, FSH)-> Normal in cluster headaches but may suggest pituitary adenoma