Diagnosis

Cluster headache

Etiology

Cause [hio]

• The exact cause is unknown

• Genetic: autosomal dominant in about 5% of cases

• Triggers: Histamine, stress, allergens, seasonal changes, nitroglycerin, alcohol, tobacco, watching television, relaxation, extreme temperatures, glare, allergic rhinitis, and sexual activity

Pathophysiology [gfp]

• Incompletely understood - several possible theories

• Central disinhibition of the autonomic nociceptive trigeminal pathway

• Vascular change is considered secondary to primary neuronal discharge

• Histamine may precipitate cluster headache, but evidence is inconsistent

Risk factors [hio]

• Male sex

• Age > 30 years

• Vasodilators (alcohol)

• Previous head trauma or surgery

Complications [hio]

• Psychiatric conditions: depression, anxiety, aggressive behavior, suicidal attempts

• Systemic autonomic dysregulation: bradycardia, tachycardia, hypertension, arrhythmias (such as AV block and SA block)

Epidemiology

Prevalence per 100.000 [ghc]

Incidence per 100.000 [ghc]

Approach

• Clinical diagnosis: A history of characteristic attacks that occur with periodicity and rhythmicity

• CT/MRI caput/neck to exclude other potential causes of headache

Treatment

1. Symptomatic: stop or reduce the severity of an acute attack

   • Oxygen: 8 L/min for 10 minutes or 100% by mask

   • Triptan: Sumatriptan 6 mg subcutaneous injection

   • Ergot alkaloid: Dihydroergotamin IV or IM

   • Metoclopramide

   • Lidocaine intranasal (1 mL of a 10% solution on a swab in each nostril)

   • Parenteral opiates (risk of abuse)

2. Preventive: to reduce the frequency and intensity of attack

   • Calcium channel blockers: Verapamil

   • Mood stabilizers: Lithium, tricyclic antidepressants

   • Anticonvulsants: Topiramate and divalproex

   • Corticosteroids

   • Invasive nerve blocks and ablative procedures: variable effect

     • Percutaneous RF ablation

     • Trigeminal gangliorhizolysis

     • Rhizotomy

     • Gamma-knife radiosurgery

     • Botulinum toxin

     • Deep brain stimulation

Differential diagnoses

Acute sinusitis, Allergic rhinosinusitis, Basilar artery thrombosis, Brain tumor, Carotid artery dissection, Cerebral aneurysm, Cerebral venous sinus thrombosis, Dental infection, Glaucoma, Herpes zoster, Horner syndrome, Ice pick headache, Intracranial hemorrhage, Medication-overuse headache, Meningioma, Migraine, Myofascial pain, Nasopharyngeal carcinoma, Optic neuritis, Pheochromocytoma, Pituitary adenoma, Preeclampsia, Prolactinoma, Subarachnoid hemorrhage, Systemic lupus erythematosus, Temporal arteritis, Tension headache, Trigeminal neuralgia