Applied Evidence

Practical strategy for detecting and relieving cluster headaches

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Diagnosis, too often delayed, is not difficult given the typical pattern, and treatment options work for most patients.


 

References

Practice recommendations
  • Learn to recognize the distinctive pattern of cluster headaches that in most cases, even if some symptoms suggest migraine, will readily reveal this disorder (C).
  • 100% oxygen by face mask and injected sumatriptan (Imitrex) are effective choices to terminate an acute attack (B).
  • Verapamil (Calan) or corticosteroids abort cluster cycles and prevent further attacks (B).

You interview a “migraine” sufferer who hopes to find the relief that has so far eluded him. During the history taking, he reports experiencing the premonitory aura typical of migraine as well as photophobia and occasionally nausea. One description, though, raises a question about the cause of his headaches: he says the intense pain recurs at roughly the same time of day and lasts for about 45 minutes; he is unable to concentrate on anything but the pain and he paces ceaselessly until it abates. The odds now favor a diagnosis of cluster headache.

Given that symptoms of migraine and cluster headaches overlap, and that migraine is more prevalent than cluster headache, recognizing the latter requires sensitivity to its key attributes described in this article.

Careful selection of therapeutic agents will hasten resolution of acute pain and prevent recurrences. Some drugs may be combined for quicker onset of action.

Telltale characteristics of cluster headaches

As shown in the opening example, cluster headache is diagnosed primarily by history (see Source of cluster headaches).

Recognize the pattern. Its most striking feature is the unmistakable pattern of repeated bouts of pain that “cluster” at the same time of the day or night.

Each attack is extremely intense and brief, typically lasting 15 to 180 minutes.

For patients with the episodic variety of cluster headaches, the pattern of repeated headaches may last days to weeks, then resolve spontaneously. The relatively few patients with the chronic form of the disorder experience an unending cycle of daily or near daily headaches.

Attacks may occur during the day or night, and often wake the patient from sleep.1

Pain is always unilateral. Location of the pain varies among patients but is usually within the distribution of the trigeminal nerve. Almost all patients (92%) have retro-orbital pain, and most (70%) also have pain in the temporal region. Pain is present in the upper teeth, jaw, forehead, or cheek half of the time. Less common sites of pain are the ears, lower jaw, neck and shoulder.1

Look for associated findings. Pain is accompanied by signs and symptoms of ipsilateral autonomic dysfunction. Lacrimation on the affected side is the most common associated feature. Rhinorrhea or a blocked nasal passage, red eye, and swelling or pallor of the forehead or cheek are often found bilaterally but are clinically dominant on the symptomatic side.

Restlessness occurs during an attack and the patient often prefers to pace about, in striking contrast to the migraine sufferer, who avoids activity so as not to exacerbate the pain. Half of cluster headache sufferers experience nausea, photophobia, or phonophobia during attacks. A smaller number (14%) report an aura similar to that of a migraine. Ninety percent of cluster headache patients who drink alcohol say it triggers headache while they are in the midst of a cluster cycle.1

Delay in diagnosis common. The 2004 revision of the International Classification of Headache Disorders, reflects our improved understanding of and ability to identify these disorders.4 The mean time to diagnosis of cluster headache has decreased from 22 years in the 1960s to 2.6 years in the 1990s, reflecting much better recognition of the syndrome.5 Nevertheless most patients consult three primary care physicians before a diagnosis is made. The time between the first episode and diagnosis ranged from 1 week to 48 years (median 3 years) in one recent study.6

Overlap of migraine and cluster symptoms may lead to misdiagnosis. Factors contributing to diagnostic delay include photophobia or phonophobia, nausea, an episodic attack pattern and a younger age at onset (P<.01). Correct diagnosis is further complicated in that 26% of cluster headache suffers also report a history of migraine headaches.1 The Key differentiating factor between the two headaches types is the predictable pattern of repeated, intense, brief head pain.

Rare underlying causes. A very few patients with headaches have brain tumors. Headache is present in 50% to 60% of newly diagnosed brain tumors, but is usually accompanied by other signs or symptoms. It is the only presenting symptom in approximately 8% of cases. Most headaches due to tumors are clinically similar to tension headache (77%), and some mimic migraine (9%). Rapidly growing tumors are more likely to be associated with constant unremitting headache. Rarely brain tumors may produce pain syndromes similar to cluster headache.7 Other causes of secondary cluster headache include infections, vascular abnormalities, and head trauma.

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