Curriculum · Neurology
Cluster headache
What it is
Cluster headache is one of the most painful conditions a patient can suffer, which is why it is known as the suicide headache. The name describes the pattern: attacks come in bouts. Primary headaches include cluster, migraine and tension. Cluster headache is more common in males; migraine and tension headache are more common in females. Of the three it is the least common: tension-type headache is the most common primary headache, migraine the second most common, and cluster headache the least common. It is rare under 20 years of age. Two patterns are separated by the length of the remission: episodic cluster headache has remissions of more than one month, and chronic cluster headache has remissions of less than one month in a 12 month period. The pathophysiology given for it is hypothalamic activation, with autonomic symptoms named beside it.
How it presents
- Pain occurs once or twice a day, each episode lasting 15 minutes to 2 hours
- Clusters typically last 4 to 12 weeks, and recurrent attacks always affect the same side, at the same time every year
- Intense sharp, stabbing, excruciating periorbital pain around one eye
- The patient is restless and agitated during an attack
- Autonomic features accompany it: redness, lacrimation, rhinorrhea, conjunctival injection, lid swelling and nasal stuffiness, with miosis and ptosis in a minority
Miosis with partial ptosis is Horner syndrome, and cluster headache is one of its postganglionic causes. Horner syndrome itself is written as a symptom triad of three things, not two: miosis, an abnormally small pupil; partial ptosis, drooping of the upper eyelid; and facial anhidrosis, absence of sweating. In cluster headache the third is left out: a note on cluster headache reads that it is associated with Horner syndrome but there is no hydrosis at all, and the features above name miosis and ptosis.
- Attack frequency is also written as one episode at least every other day, up to eight episodes per day, and elsewhere as from once every 2 days to 8 times a day
- Onset is often predictable, and recurrences affect the same side
- Triggers named are alcohol, strong smells and bright light