Headache, Cluster is a topic covered in the 5-Minute Clinical Consult.
5-Minute Clinical Consult Explore these free sample topics:
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- Primary headache disorder
- Multiple attacks of unilateral, excruciating, sharp, searing, or piercing pain. Typically localized in the periorbital area and temple accompanied by signs of ipsilateral autonomic features.
- Autonomic symptoms: parasympathetic hyperactivity signs (ipsilateral lacrimation, eye redness, nasal congestion) and sympathetic hypoactivity (ipsilateral ptosis and miosis)
- Patients often pace, rubbing their heads to try to alleviate the pain.
- Symptoms usually remain on the same side during a single cluster attack.
- Individual attacks last 15–180 minutes if untreated and occur from once every other day to 8 times per day.
- Attacks usually occur in series (cluster periods) lasting for weeks or months separated by remission periods usually lasting months or years. However, about 10–15% of patients have chronic symptoms without remissions.
1-year incidence: 53/100,000
- Lifetime prevalence 124/100,000 (∼0.1%)
- Predominant sex: male > female (4.3:1)
- Mean age of onset: between 29.6 and 35.7 years
- Episodic/chronic ratio 6:1
Etiology and Pathophysiology
- Complex and incompletely understood
- Proposed mechanisms include the following:
- Activation of posterior hypothalamus may trigger an attack, causing activation of the trigeminal nerve, leading to intense pain symptoms.
- Autonomic symptoms: activation of craniofacial parasympathetic nerve fibers secondary to pathologic activation of trigemino-autonomic brainstem reflex
- Usually sporadic: autosomal dominant in 5% of cases, autosomal recessive or multifactorial in other families
- Evidence varies: 1st-degree relatives carry 5–8-fold; 2nd degree 1–3-fold increased relative risk of disease
- Male gender
- Age (70% onset before age 30 years)
- Cigarette smoking
- Family history of cluster headache (CH)
- Head trauma
- Alcohol induces attacks during a cluster but not during remission.
- Small amounts of vasodilators (e.g., alcohol, nitroglycerin, sildenafil)
- Strong odors
Commonly Associated Conditions
- Depression (24%)
- Increased risk of suicide secondary to the extreme nature of the pain
- Medication overuse headache
- Asthma (9%)
- History of migraine, frequently in female patients
- Sleep apnea (14%)
- Increased prevalence of cardiac right-to-left shunt and patent foramen ovale (relationship unclear)