Cluster Headache

 

Cluster headache is a disorder characterized by very intense painful attacks in the face (most often around the eye and temple). The pain is usually associated with a stuffy or runny nose, tearing, and eye redness. The diagnosis is clinical. The crisis treatment is based on taking anti-migraine medications (triptans or dihydroergotamine) or telehealth psychiatry services. Some medicines can be prescribed for prevention, for example, verapamil, lithium, topiramate, or valproate.

Definition and Symptoms

What Is Cluster Headache?

Cluster headache mostly affects men and usually starts between the ages of 20 and 40. The origin of this type of pathology is unknown; dysfunction of the hypothalamic gland is mentioned. Indeed, during a crisis, an area linked to the hypothalamus functions abnormally and activates the structures responsible for pain in the face. Reflexively, the vegetative nervous system causes tearing, nasal congestion, and various other associated symptoms.

To know! The hypothalamus is a brain construction that controls wake-sleep cycles and the production of various hormones.

Usually, cluster headaches are episodic. The attacks can last between 1 and 3 months, with more or less one attack per day. A phase of remission (that is, without symptoms) can last several months or even years. The seasonality of the disease is fairly standard, with 1 to 2 episodes per year.

In other cases, cluster headache progresses without remission. We then speak of chronic cluster headache, which concerns 10% of patients.

To note! Alcohol consumption can trigger cluster headaches in crisis times, but not when the patient is in remission.

The prevalence of cluster headache in the population is estimated at around 0.1%. There is a clear male preponderance. The average age of onset is around 28 years.

What Symptoms?

In general, a cluster headache attack lasts between 15 minutes and 3 hours. Seizures often occur at the same time every day. There are no warning signs of the crisis.

The symptoms are very characteristic.

The pain is always one-sided and occurs on the same side of the face in the orbitotemporal region (between the eyes and the temples). The pain is extremely violent. It is defined by patients as a "burning", "feeling of tearing", "crushing", "like a knife which one pushes in and which one turns," or even like "a hot iron which burns. the eye ". It reaches its maximum in a few minutes and disappears spontaneously in 30 minutes to 1 hour. The pain can manifest itself in sleep and wake the patient up. Note that the pain localized in the orbital region radiates to the forehead, temple, cheekbone, cheek, or gum in many cases. Although in the infinite majority of cases, the pain affects only one side of the face,

Patients in crisis are restless (as opposed to migraine patients who seek, on the contrary, calm). Individuals in crisis cannot lie down, wander very often, and sometimes even hit their heads against the walls. The patient usually compresses or hides the painful eye with the hand. Some patients say they want to tear out their eyes or throw themselves out the window because the pain is so unbearable.

Vegetative symptoms occurring on the same side as the headache are associated:

·         Nasal congestion ;

·         Tearing;

·         Runny nose ;

·         Redness of the face;

·         Claude Bernard Horner syndrome (after the seizure, the eyelid on the affected side may drop, and the pupil may contract).

After the crisis, in addition to Claude Bernard Horner syndrome, other very characteristic manifestations may be associated: the region below the eye is swollen, the eye oozes, and nausea.

There is no risk of complications. Even very painful seizures do not damage the brain. There is no link between the disease and aneurysms or other deformities.

Diagnosis and Treatment

What Diagnosis?

The diagnosis is, first of all, clinical, based on the questioning of the patient. It is based on the presence of headaches and associated symptoms characterizing the disease and excluding any intracranial abnormality. Other pathologies are excluded by performing an MRI (magnetic resonance imaging) of the head or a CT (computed tomography). Note that given the specificity of the symptoms, it is rare to perform additional examinations to diagnose. They are usually performed only when the symptomatology is not typical.

Cluster headache is a little-known disease. The diagnostic time is, on average, four years. This is because seizures are very reminiscent of tooth pain or sinusitis, and patients are often treated accordingly, delaying diagnosis.

What Treatment?

The attack treatment corresponds to the injection of dihydroergotamine or triptans (molecules usually used in the treatment of the migraine attack) or to the putting on oxygen.

In all patients with frequent, severe, and debilitating cluster headaches, preventive treatment may be initiated. It consists of :

·         Taking a corticosteroid (prednisone) by mouth or infiltrating the occipital nerve to obtain rapid but temporary anesthesia;

·         And taking certain drugs, including verapamil, lithium, topiramate, or valproate, has a slower onset of action.

Of the crisis treatments that provide rapid pain relief, the main one is injectable sumatriptan. It can be twice in 24 hours, respecting a 1-hour interval between 2 doses. Any heart problem is a contraindication to its use. Note that it also exists in the form of a nasal spray.

High flow oxygen can be used with a mask for patient relief. However, it works less quickly than sumatriptan. It is, however, without contraindication or restriction of use. It must be prescribed and renewed by a neurologist, an algologist (pain doctor), or an ENT doctor.