CLUSTER HEADACHE

Definition
 Primary neurovascular primary headache disorder

 Characterized by : -
 severe strictly unilateral (retro-orbital or periorbital)
 short-lasting headaches (few seconds to 2 hours)
 prominent cranial facial parasympathetic
autonomic features (ipsilateral lacrimation, nasal congestion,
conjunctival injection, miosis, ptosis, and lid edema)

 Cluster - a clustering of painful attacks over a

period of many weeks.
Classification
 Diagnostic Criteria
• A. At least 5 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 at least 1 of the following:
• Ipsilateral conjunctival injection and/or lacrimation
• Ipsilateral nasal congestion and/or rhinorrhoea
• Ipsilateral eyelid oedema
• Ipsilateral forehead and facial sweating
• Ipsilateral miosis and/or ptosis
• A sense of restlessness or agitation
• D. Attacks have a frequency from 1 every other day to 8/day
• E. Not attributed to another disorder
•  References:
• International Headache Society. The International Classification of Headache Disorders, 2nd Edition. Cephalalgia 2004; 24
(suppl 1): 1-160 (www.i-h-s.org)
 EPIDEMIOLOGY AND RISK
FACTORS

• About 0.4% of the general population

• Male:female ratio of 5:1
• Can occur at any age including childhood and
adolescence (rare before the age of 10) but
usually begins in the third or fourth decade of life
 Triggering Factors
• Alcohol and cigarette smoking
• High altitudes (air travel)
• Bright light (including sunlight)
• Exertion
• Heat (hot weather, hot baths)
• Foods high in nitrites (such as preserved
meats)
• Certain medications
• Cocaine
 History
 No aura exists as in migraines

 Periodicity is the most striking characteristic

 1-2 cluster periods per year, each lasting 2-3 months

 Pain
 Sudden onset - Peaks in 10-15 minutes
 Unilateral facial - Remains on the same side during the cluster period
 Duration - 10 minutes to 3 hours per episode
 Character – excruciating, explosive and deep as if eye is being pushed
out
 Distribution - First and second divisions of the trigeminal nerve
(Approximately 18-20% of patients complain of pain in the
extratrigeminal areas [eg, back of the neck, along carotid artery].)
 Frequency - May occur several times a day for 1-4 months (often
nocturnal)
 Periodicity - Circadian regularity in 47%
 Remission - Long symptom-free intervals occur in some patients. The
average remission is 2 years but ranges from 2 months to 20 years
 History
 Lacrimation (84-91%) or conjunctival injection

 Nasal stuffiness (48-75%) or rhinorrhea

 Ipsilateral eyelid edema

 Ipsilateral miosis or ptosis

 Ipsilateral forehead and facial perspiration (26%)

 Restlessness/agitation (90%)
 Physical Examination
 Parasympathetic overactivity
 Ipsilateral lacrimation
 Conjunctival injection
 Rhinorrhea or congestion
 Ocular sympathetics paralysis - Mild Horner syndrome (eg, ptosis,
miosis, anhidrosis)
 Bradycardia
 Facial flushing or pallor
 Scalp and facial tenderness
 Ipsilateral carotid tenderness (in some patients)
 Patient often is in severe distress.
 Patient may lower the head and press on the site of pain, sometimes
crying or screaming.
 Physical exercise may help some patients obtain relief.
 Patient may threaten suicide.
TREATMENT
 Prophylaxis
• Amitriptyline
• Propranolol
• Verapamil
• Topiramate
 Definitive Treatment
• Triptans ( eg: sumatriptan )
• Anti-inflammatory (steroid ) eg:
prednisone
• Breathing in 100% (pure) oxygen
• Injections of dihydroergotamine (DHE)
Thank You