Cluster headache

Attack of severe pain localized to the unilateral orbital, supraorbital, and/or temporal areas; lasts from 15 minutes to 3 hours. Occurs from once every other day to 8 times per day.

Attacks occur at the same time period for several weeks (the cluster period); accompanied by ipsilateral autonomic signs. Most patients are restless or agitated during attacks compared to people with migraine who often report motion sensitivity during attacks.

Pathophysiology is thought to result from hypothalamic activation with secondary trigeminal and autonomic activation. Cluster period attacks can be precipitated by alcohol, volatile smells, warm temperatures, and sleep.

Diagnosis is based on International Headache Society 3-beta (IHS-3b) criteria.

Medications for acute treatment should be used in combination with prophylactic medications.

Greater occipital nerve blockade often provides relief until preventive medications take effect. Neurostimulation techniques have provided dramatic response in patients with chronic cluster headaches that are refractory to medical treatments. Invasive neurostimulation techniques employed in cluster headache include occipital nerve stimulation and posterior hypothalamic region deep brain stimulation. Emerging techniques include invasive sphenopalatine ganglion stimulation and noninvasive vagal nerve stimulation.

Cluster headache is considered one of the most painful conditions known to humanity. The clinical picture consists of unilateral headache attacks lasting 15 to 180 minutes, associated with autonomic symptoms secondary to parasympathetic hyperactivity and sympathetic hypoactivity. Some patients will develop chronic cluster headache and experience daily attacks without periods of remission. Pain is often localized to the unilateral orbital, supraorbital, and/or temporal areas and can occur from once every other day to 8 times per day.

During an attack the pain is strictly unilateral, although some patients report the pain shifting sides between or during bouts but not during the attack itself. Both cluster bouts and attacks during a cluster period can show cyclical periodicity occurring at the same time of year or the same time of day. Autonomic features accompanying pain include ptosis, conjunctival injection, lacrimation, rhinorrhea, nasal stuffiness, eyelid and facial swelling, aural fullness, facial sweating, and redness. Most patients become very restless or agitated during an acute attack, unlike people with migraine who often report motion sensitivity during attacks.

Ninety percent of patients will have episodic cluster headache,[1]Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology. 2002 Feb 12;58(3):354-61. http://www.ncbi.nlm.nih.gov/pubmed/11839832?tool=bestpractice.com which consists of attacks lasting from 7 days to 1 year (averaging from 2 weeks to 3 months), separated by remission periods lasting at least 1 month. The chronic form of cluster headache is seen in approximately 10%[1]Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology. 2002 Feb 12;58(3):354-61. http://www.ncbi.nlm.nih.gov/pubmed/11839832?tool=bestpractice.com and consists of attacks that occur for more than 1 year, with less than 1 month's remission.[2]Headache Classification Committee of the International Headache Society (IHS). The international classification of headache disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808. http://www.ihs-classification.org/_downloads/mixed/International-Headache-Classification-III-ICHD-III-2013-Beta.pdf http://www.ncbi.nlm.nih.gov/pubmed/23771276?tool=bestpractice.com The condition may be chronic from onset or may evolve over time from the episodic form.