HeadWise Volume 4, Issue 3 | Page 12

CLUSTER HEADACHE THE MOST SEVERE HEADACHE George Urban, MD Co-Director Diamond Headache Clinic Diamond Inpatient Headache Unit Presence-Saint Joseph Hospital Chicago, Illinois Cluster Headache has been described as the most painful type of headache one can endure. Fortunately, it is not very common. Cluster headache is one of the primary headaches that is not caused by other disorders. Although this headache was recognized for at least a century, the term, Cluster Headache, was coined relatively recently, in 1952 by Doctor E. Charles Kunkle and his colleagues. Prior to this title, cluster headache was known under a variety of names including: Migrainous neuralgia; Horton’s headache; Harris-Horton’s disease; Histaminic Cephalalgia; Ciliary neuralgia; and, Erythromelalgia of the head. In 1745, Gerhard van Swieten presented a case of a “healthy, robust man of middle age [who] was suffering from troublesome pain which came on every day at the same hour at the same spot above the orbit of left eye…” This description fulfills the current diagnostic criteria of Cluster Headache. How common is this disorder? Cluster headache is a relatively uncommon headache disorder. The prevalence is about 10 per 100,000 in male patients, which is about 19 to 25 times less than the prevalence of migraine headache in men. Most cluster headache sufferers are males, with the gender ratio varying 12 HeadW ise ® | Volume 4, Issue 3 • 2015 from 3.5:1 to 6.7:1 in favor of males. No racial, ethnic, or genetic factor has been documented. Cluster headache can begin at any age, but the average mean age of onset is during the late 20s and early 30s. What is characteristic for this condition? The acute attack of cluster headache occurs suddenly, without any warning. It peaks in intensity within 10 to 15 minutes, and lasts usually from 40 to 90 minutes. The pain is excruciating and described most commonly as boring, burning, piercing, sharp, knife-like, or “a hot poker in the eye.” A soreness or lingering dull pain may persist for hours after the main attack. The pain is strictly one-sided, and occurs on the same side at the same location during a cycle. It may change sides in the next cycle. The typical location is at the temple, above the eye, or behind the eye. The area of pain is small, and often the patient can point to the pain’s location with the tip of a finger. The headache has been described as the most severe form of pain a human can endure. It is not unusual for women who experience cluster headache to describe the pain as worse than the pain associated with labor and delivery. The cluster headache has been nicknamed by some sufferers as the “killer” or “suicide” headache. The headache episodes occur in peculiar periodicity. The term “cluster” derives from attacks occurring repeatedly within a relatively limited time span, called the period, cycle, bout, or cluster. On average, a cluster cycle lasts 6 to 12 weeks. Many patients experience one cycle every year, usually at the same time each year. Typically, cluster headaches manifest during spring or autumn, a phenomenon called circannual rhythm. During the cycle, the attacks appear daily, usually once a day at the same time–circadian periodicity. In between the cycles, the patient is completely headache-free. More than 50 percent of cluster patients report that the attacks occur at night, most commonly about 2 to 3 hours after falling asleep. Many patients will have their attacks at a predictable rate. The number of attacks usually do not exceed three in 24 hours. However, some patients with chronic cluster headache may experience more than five attacks a day. The typical symptoms, which must be present for the correct diagnosis, are autonomic responses. These responses include eye tearing and redness, runny nose and congestion, sweating of half of the face, and sometimes a droopy eyelid. These symptoms occur on the same side of the headache, and continue throughout the entire attack. Nasal congestion and runny nose may lead to an incorrect diagnosis of sinus headache or sinus infection. Some patients may also experience nausea, vertigo, neck muscle stiffness or tenderness, and possibly fluctuations in the heart rate and blood pressure. Another distinguishing feature of cluster headache is the behavior of patients during the attacks. As opposed to migraine sufferers,