Cluster headache
Description
- The prototypical trigeminal autonomic cephalalgia (TAC): strictly unilateral pain in V1 distribution + ipsilateral cranial autonomic features + agitation
- The most severe pain in clinical medicine ("suicide headache")
The attack
- Severe orbital/supraorbital/temporal pain, strictly unilateral, side-locked within a bout
- Duration 15-180 min untreated
- Frequency 1 every other day to 8/day
- Circadian and circannual periodicity - same time each night (classically ~1-2 h after falling asleep), bouts in the same season each year
- Restlessness and agitation - pacing, rocking, head-banging
- *The single best discriminator from migraine, where the patient lies still in the dark*
- Ipsilateral autonomic features: conjunctival injection, lacrimation, nasal congestion/rhinorrhoea, eyelid oedema, forehead/facial sweating, ptosis and miosis (partial Horner, may persist between attacks)
- Alcohol, nitrates and altitude trigger attacks during a bout only, not in remission - a pathognomonic pattern
Patterns
- Episodic (~80-90%) - bouts lasting weeks to months, separated by remissions >=3 months
- Chronic (~10-20%) - <3 months remission in 12 months; harder to treat
Trigeminal autonomic cephalalgias - the family
| Duration | Frequency | Defining response | |
|---|---|---|---|
| Cluster | 15-180 min | 1 alt. day - 8/day | Oxygen, sumatriptan SC |
| Paroxysmal hemicrania | 2-30 min | >5/day | *Absolute response to indometacin* |
| SUNCT/SUNA | 1-600 s | Up to 200/day | Lamotrigine |
| Hemicrania continua | Continuous with exacerbations | - | *Absolute response to indometacin* |
- *Every strictly unilateral headache deserves an indometacin trial* - missing paroxysmal hemicrania or hemicrania continua means years of unnecessary suffering
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