Cluster Headache
At the City of London Migraine Clinic we have one specialist, Dr JN Blau who has become particularly interested in this condition and has seen about 700 people.
There are effective treatments available and we are happy to see any patients who may have cluster headache with a letter from their GP or referring doctor.
Cluster headache is rare - about 1 in 5000 people; on the whole it starts 10 to 15 years later than the usual onset of migraine.The underlying pathophysiology remains elusive. The condition is a predominantly male disorder with a male: female ratio of 5:1. The age at onset is during the late 20s and the patient often smokes or has a history of smoking. A family history of cluster headache is rare. As the name suggests, attacks come in clusters once or twice a year lasting an average of 6-8 weeks. A few patients have chronic cluster headache with no periods of remission from attacks.
The clinical history is characteristic and quite different from migraine. During a cluster period, patients experience an average of 1 to 3 attacks each day of very severe unilateral pain lasting between 20 and 120 minutes. Attacks often wake the patient from sleep at the same time every night. The pain builds up rapidly to peak within a few minutes of onset. The headache always occurs on the same side during each cluster and is usually centred over one eye which waters and appears bloodshot. The nostril on the affected side is blocked and there may be a discharge. The contralateral side is completely unaffected. The patient prefers to be left alone and paces up and down, often holding his head, rocking it back and forth. He may put pressure on the painful area or rub sufficiently hard to cause bleeding. The pain is so severe and intense that some patients may become violent during an attack or repeatedly hit their heads. Symptoms subside rapidly but the area around the affected eye may feel ‘bruised’ between attacks.
Alcohol may trigger attacks but only during the cluster. Sublingual nitroglycerin and histamine can also provoke attacks. No other triggers have been identified and avoidance of migraine triggers is irrelevant. Apart from migraine, the differential diagnoses include trigeminal neuralgia, temporal arteritis or more rarely, phaeochromocytoma or chronic paroxysmal hemicrania.
FURTHER READING:
1. Kudrow L. Cluster Headache: Mechanisms and management. London, Oxford University Press 1980.
2. Sjaastad O. Cluster Headache Syndrome. Major Problems in Neurology Vol 23. London, WB Saunders Company Ltd 1992.
3. Blau JN. Behaviour during a cluster headache. Lancet 1993; 342: 723-725. Unlike migraine it is more common in men than women. Hence this typical picture described in an article for doctors, written by Dr Blau who studied 50 patients.