Cluster headache

Background

• Occur most often in middle aged men
• Classically occur in "clusters" over days to weeks typically at the same time of day and same anatomical location.
• Triggers may be alcohol, nitroglycerin, histamine

Definition

At least 5 attacks of headache fulfilling the following criteria:

1. Severe unilateral orbital, supraorbital, or temporal pain lasting 15–180 min if untreated
2. Headache accompanied by at least one of the following:
   • Ipsilateral conjunctival injection and/or lacrimation
   • Ipsilateral nasal congestion and/or rhinorrhea
   • Ipsilateral eyelid edema
   • Ipsilateral forehead and facial sweating
   • Ipsilateral miosis and/or ptosis
   • A sense of restlessness or agitation
3. Attacks have a frequency from one every other day to eight per day
4. Not attributed to another disorder

Differential Diagnosis

Headache

Common

• Migraine headache
• Tension headache
• Cluster headache

Killers

• Meningitis/encephalitis
• Retropharyngeal abscess
• Intracranial Hemorrhage (ICH)
  • SAH / sentinel bleed
• Acute obstructive hydrocephalus
• Space occupying lesions
• CVA
• Carbon monoxide poisoning
• Basilar artery dissection
• Preeclampsia
• Cerebral venous thrombosis
• Hypertensive emergency
• Depression

Maimers

• Temporal arteritis
• Idiopathic intracranial hypertension (aka Pseudotumor Cerebri)
• Acute Glaucoma
• Acute sinusitis
• Cavernous sinus thrombosis or cerebral sinus thrombosis

Others

• Trigeminal neuralgia
• TMJ pain
• Post-lumbar puncture headache
• Dehydration
• Analgesia abuse
• Various ocular and dental problems
• Herpes zoster ophthalmicus
• Herpes zoster oticus
• Cryptococcosis
• Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
• Ophthalmoplegic migraine
• Superior Vena Cava Syndrome

Aseptic Meningitis

• Viral
  • Varicella
  • Herpes
  • Enterovirus
  • West Nile
• Tuberculosis
• Lyme disease
• Syphilis
• Drug induced aseptic meningitis
• Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
• Noninfectious
  • Sarcoidosis
  • Vasculitis
  • Connective tissues disease

Evaluation

• Consider other emergent causes of headache based on H&P
  • Consider CT, LP, and/or eye pathology
• Typically a clinical diagnosis

Management

• High-flow O2 (effective in 70% of patients)
• Intranasal lidocaine 4%
• DHE
• Sumatriptan
• Intranasal zolmitriptan
• Subcutaneous or IM dihydroergotamine and intranasal sumatriptan are additional options

Disposition

• Normally outpatient

See Also

• Headache

References

Authors

Ross Donaldson