Chapter 20-6: Cluster Headaches

TEXTBOOK PRESENTATION

Cluster headaches are severe headaches that occur in young men, often beginning in their 20s. The headache is unilateral, usually occurring around the eye or temporal region and is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, or rhinorrhea. Sufferers are often restless during attacks.

DISEASE HIGHLIGHTS

1. The prevalence of cluster headaches is about 0.1%. They are more common in men than women (4:1).

2. The headaches are unilateral, severe, and are associated with autonomic findings related to both parasympathetic overactivity and sympathetic underactivity.

3. Cluster headaches are generally brief, lasting from 15 minutes to 3 hours.

4. The headaches occur in clusters with frequent headaches occurring for 6–12 weeks before a headache-free period.

EVIDENCE-BASED DIAGNOSIS

1. Classic cluster headaches present in a memorable, stereotypical way.

2. The IHS criteria for a cluster headache are:

   1. The patient must have at least 5 attacks.

   2. The headache must last 15–180 minutes; be severe; and be characterized by unilateral pain that is orbital, supraorbital, or temporal.

   3. The headache is accompanied by at least 1 of the following:

      1. Ipsilateral conjunctival injection and/or lacrimation

      2. Ipsilateral nasal congestion and/or rhinorrhea

      3. Ipsilateral eyelid edema

      4. Ipsilateral forehead and facial sweating

      5. Ipsilateral miosis and/or ptosis

      6. A sense of restlessness or agitation

   4. Attacks occur anywhere from every other day to 8/day during a cluster.

TREATMENT

1. Treatment for cluster headaches is similar to the treatment for migraines — either acute abortive or prophylactic therapies may be used.

2. Abortive therapy

   1. High-flow oxygen is the treatment with the least side effects and best evidence base.

   2. Triptans, similar to those used in the treatment of migraines, are also effective.

3. Prophylactic therapy

   1. Verapamil is usually considered the first-line therapy for preventing cluster headaches.

   2. Corticosteroids and topiramate have also been used successfully.