Cluster Headache

History Taking

Chief Complaint:

• Severe, unilateral headache

History of Presenting Complaint:

• Described as excruciating, sharp, or burning pain localized around one eye or temple

• The headache peaks rapidly, within 5 to 10 minutes

• The headache lasts for 15 minutes to 3 hours, recurring up to several times per day for weeks or months

• Associated symptoms include restlessness or agitation

• The headache often occurs at the same time every day, often waking the patient in the early morning hours

System Review:

• Autonomic symptoms are common during the headache, such as redness and tearing of the eye, drooping of the eyelid (ptosis), constriction of the pupil (miosis), and nasal congestion or runny nose on the side of the headache

• Less common symptoms may include facial sweating, facial flushing, or a sense of fullness in the ear on the side of the headache

• No visual aura like in migraines

• No systemic symptoms like fever, weight loss

Past Medical History:

• Previous episodes of similar headaches, often with periods of remission lasting months to years

• No history of major medical illnesses

Past Surgical History:

• Likely to be unremarkable

Drug History:

• Use of over-the-counter pain relievers, which typically provide little relief

• History of specific treatments for cluster headache, such as sumatriptan, oxygen therapy, or preventive medications like verapamil

Family History:

• Possible history of cluster headaches or other types of headaches in the family, although genetic predisposition is not clearly established

Personal History:

• Possible history of smoking or alcohol use, which can be triggers for cluster headache attacks but are not causative

Social History:

• The severe pain and unpredictability of the headaches can lead to significant stress and anxiety, impacting the patient's work and personal life

Physical Examination

General Examination:

• Patient may appear restless or agitated due to the pain

• Patient may pace or rock back and forth

Examination of Face:

• Unilateral redness and tearing of the eye

• Drooping of the eyelid (ptosis) and constriction of the pupil (miosis) on the same side as the headache

• Facial flushing or sweating on the side of the headache

• Nasal congestion or runny nose on the side of the headache

Neurological Examination:

• Cranial nerves: Findings consistent with Horner's syndrome (ptosis, miosis, and anhidrosis) on the side of the headache

Additional Examination:

• Blood pressure: Might be elevated due to pain

• Temporal artery examination for any signs of inflammation or tenderness to exclude temporal arteritis in older patients presenting with new-onset headache

Investigations

Laboratory Investigations:

• Complete Blood Count (CBC): To rule out infection or systemic cause of headache such as anemia

• Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP): To exclude temporal arteritis in older patients presenting with new-onset headache

• Liver and Kidney function tests: Baseline before starting medications like verapamil which may affect these organ functions

Imaging:

• MRI Brain: To rule out structural lesions like brain tumor, aneurysm, or arteriovenous malformation that may present as a headache

• MR angiography or venography if suspecting vascular causes of headache

Invasive Tests:

• Lumbar puncture: To exclude conditions such as subarachnoid hemorrhage or meningitis if there is a high index of suspicion based on other symptoms or signs

Management

General Management:

• Explanation and reassurance: Explain the nature of the condition, its prognosis, and the treatment options

• Lifestyle modification: Identify and avoid triggers such as alcohol and tobacco, maintain a regular sleep schedule

Medical Management:

• Acute attacks: High-flow oxygen (100% oxygen at 12 liters per minute for 15-20 minutes) or sumatriptan (6 mg subcutaneous)

• Preventive therapy: Verapamil (starting dose 80 mg three times a day, up to 480 mg/day), lithium, topiramate, or prednisone for short-term prevention

• Steroid taper: Can be used as a bridge until preventive medications take effect

• Melatonin: Some evidence for use in prevention

Surgical Management:

• Occipital nerve stimulation: For patients with chronic cluster headaches that have not responded to medications

• Deep brain stimulation: Only for severe, refractory cases

• Percutaneous procedures such as radiofrequency ablation, glycerol injection, or balloon compression of the trigeminal ganglion: Reserved for refractory cases

Other:

• Psychological support: Due to the high burden of disease, some patients may benefit from cognitive behavioral therapy or other psychological interventions

• Regular follow-up: Monitor the response to treatment and adjust as necessary