Cluster Headache –  aka – migranous neuralgia
Account for <1% of all headaches
This is a unilateral pain that typically wakes the patient during the night, so called, because attacks occur in ‘clusters’ – e.g. many attack in the space of a week, then no attacks for several months. The typical patient is male aged 30-40. Alcohol often precipitates attacks.

Epidemiology and Aetiology

  • 10-50x less common than migraine
  • M:F – 5:1
  • Often disappear after the age of 55
  • Patients are often smokers with a high alcohol intake, although there are no proven aetiological factors, and no genetic links

Clinical features

  • Episodic, Intense, unilateral pain – usually around one eye, increasing in intensity over 30-60 minutes, and then lasting anywhere between 30-90 minutes.
    • Typically, episodes occur grouped together – e.g. several in one week, then nor more attack for several months.
    • Can have 2 or more attack in one day
    • In some patients it is chronic, and there are no periods without attacks
  • Usually occurs in the early hours of the morning
  • Unilateral lacrimation and post-nasal drip. Eye may be become bloodshot, and the lid may swell.
  • Miosis and ptosis can occur, and in 5% of cases this can be permanent.
  • Vomiting
  • Feeling of congestion of the sinuses unilaterally
  • Transient ipsilateral Horner’s Syndrome

Pathology

On fMRI scans there is often changes in the grey matter of the hypothalamus. Some believe that it is caused by superficial temporal artery overactivity in response to 5-HT.

Treatment

Analgesia is often not very useful.
Acute attack:
  • 100% oxygen – use a non-rebreathing mask at 7-15L for around 15 minutes
  • Subcutaneous sumatriptan – mg at onsent of attack
Other acute therapies, such as those for migraine are not thought to be effective
Prophylaxis
Usually ineffective, but some patients may get benefit from:
  • Verapamil80-120mg every 8 hours
  • Corticosteroids – short courses
  • Methysergide – 4-10mg/day for up to 3 months

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