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10/7/2015

ClusterHeadacheClinicalPresentation:History,PhysicalExamination

ClusterHeadacheClinicalPresentation
Author:MichelleBlanda,MDChiefEditor:TarakadSRamachandran,MBBS,FRCP,FRCPCmore...
Updated:Apr08,2014

History
Attacksofclusterheadache(CH)aretypicallyshortandoccurwithaclear
periodicity,particularlyduringsleeporearlymorninghours,usuallycorresponding
withonsetofrapideyemovement(REM)sleep. [5]Unlikemigraine,CHisnot
precededbyauraandisnotusuallyaccompaniedbysymptomssuchasnausea,
vomiting,photophobia,orosmophobia.Typically,apatientexperiences12cluster
periodsperyear,eachlasting2weeksto3months.
TheInternationalHeadacheSociety(IHS)classifiesCHasepisodicorchronicon
thebasisofdurationasfollows[3]:
EpisodicCHoccursinperiodslastingfrom7daysto1yearclusterattacks
areseparatedbypainfreeintervalsatleast1monthlong
ChronicCHpersistsformorethan1yeareitherwithoutremissionorwith
remissionsshorterthan1monthitisfurtherdividedinto2subcategories,
chronicCHfromonsetandchronicCHevolvingfromepisodicCH
ThepainofCHismanifestedasfollows:
CharacterExcruciating,stabbing,sharp,andlancinating(asiftheeyeis
beingpushedout),ratherthanthrobbing
LocationUnilateral,intheperiorbital,retroorbital,ortemporalregions,
thoughpainsometimesradiatestothecheek,jaw,occipital,andnuchal
regionsthepaintendstoremainonthesamesideduringtheclusterperiod
butinrarecasesmayswitchsides
DistributionFirstandseconddivisionsofthetrigeminalnerve
approximately1820%ofpatientscomplainofpainintheextratrigeminal
areas(eg,thebackoftheneck,alongthecarotidartery)
OnsetSudden,peakingin1015minutes
Duration5minutesto3hoursperepisode
FrequencyMayoccur18timesadayforaslongas4months(often
nocturnal)
PeriodicityCircadianregularityin47%
RemissionLongsymptomfreeintervalsoccurinsomepatientsthelength
oftheseremissionsaverages2yearsbutmayrangefrom2monthsto20
years
Painisaccompaniedbyvariouscranialparasympatheticsymptoms,includingthe
following[5]:
Ipsilaterallacrimation(8491%)orconjunctivalinjection
Nasalstuffiness(4875%)orrhinorrhea
Ipsilateraleyelidedema
Ipsilateralmiosisorptosis
Ipsilateralforeheadandfacialperspiration(26%)
Alcoholicproductsandtobaccomayprecipitateanattack.Othertriggersincludehot
weather,watchingtelevision,nitroglycerin,stress,relaxation,extremetemperatures,
glare,allergicrhinitis,andsexualactivity.
DuringanattackofCH,asmanyas90%ofpatientsmaybecomeagitatedand
extremelyrestless.Theydonotliketoliedowntorestinstead,theyprefertopace
ormovearound.Indesperation,patientsmayrock,sit,pace,bangthemselves
againstahardsurface,screaminpain,orcrawlonthefloor.
StructurallesionshavebeendescribedwithCHandshouldbesuspectedifthe
presentationisatypical.Atypicalfeaturesmayincludethefollowing:
Absenceofaperiodicpattern
Residualheadachebetweenexacerbations
Bilaterality
Incompleteorminimalresponsetostandardtherapy
Presenceoflateralizingfindingsonexamination(otherthanHorner
syndrome)

PhysicalExamination
Physicalexaminationfindingsshouldbenormal,exceptforcertainfindingsthat
serveashallmarksofCH.Theseaccompanyingfindingsareconsistentwith
ipsilateralautonomicfeaturescharacterizedbycranialparasympatheticactivation
andsympathetichypofunction.Thepresenceofotherabnormalitiessuggests
anotheretiologyfortheheadache.
Characteristicfindingsincludethefollowing:
DistinctivefacialappearanceLeoninefacies,multifurrowedandthickened
skinwithprominentfolds,abroadchin,verticalforeheadcreases,andnasal
telangiectasias
ParasympatheticoveractivityIpsilaterallacrimation,conjunctivalinjection,
rhinorrheaorcongestion
OcularsympatheticparalysisMildHornersyndrome(eg,ptosis,miosis,and
anhidrosis),whichmaypersistbetweenattacks

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10/7/2015

ClusterHeadacheClinicalPresentation:History,PhysicalExamination

Bradycardia
Facialflushingorpallor
Scalpandfacialtenderness
Ipsilateralcarotidtenderness(insomepatients)
Patientsoftenareinseveredistress.Theymaylowertheheadandpressonthe
siteofpain,sometimescryingorscreaming.Physicalexercisemayaffordadegree
ofrelief.Incasesofespeciallysevereorintolerablepain,patientsmayeven
threatensuicide.
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
MichelleBlanda,MDChairEmeritus,DepartmentofEmergencyMedicine,SummaHealthSystemAkron
City/StThomasHospitalProfessorofEmergencyMedicine,NortheasternOhioUniversitiesCollegeofMedicine
MichelleBlanda,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
Coauthor(s)
RimaMDafer,MD,MPH,FAHAAssociateProfessor,DepartmentofNeurologyandNeurologicalSurgery,
LoyolaUniversity,ChicagoStritchSchoolofMedicine
RimaMDafer,MD,MPH,FAHAisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Neurology,AmericanHeartAssociation,AmericanHeadacheSociety
Disclosure:Nothingtodisclose.
ChiefEditor
TarakadSRamachandran,MBBS,FRCP,FRCPCProfessorEmeritusofNeurologyandPsychiatry,Clinical
ProfessorofMedicine,ClinicalProfessorofFamilyMedicine,ClinicalProfessorofNeurosurgery,StateUniversity
ofNewYorkUpstateMedicalUniversityNeuroscienceDirector,DepartmentofNeurology,CrouseIrving
MemorialHospital
TarakadSRamachandran,MBBS,FRCP,FRCPCisamemberofthefollowingmedicalsocieties:American
CollegeofInternationalPhysicians,AmericanHeartAssociation,AmericanStrokeAssociation,American
AcademyofNeurology,AmericanAcademyofPainMedicine,AmericanCollegeofForensicExaminersInstitute,
NationalAssociationofManagedCarePhysicians,AmericanCollegeofPhysicians,RoyalCollegeofPhysicians,
RoyalCollegeofPhysiciansandSurgeonsofCanada,RoyalCollegeofSurgeonsofEngland,RoyalSocietyof
Medicine
Disclosure:Nothingtodisclose.
Acknowledgements
JosephCarcioneJr,DO,MBAConsultantinNeurologyandMedicalAcupuncture,MedicalManagementand
OrganizationalConsulting,CentralWestchesterNeuromuscularCare,PCMedicalDirector,OxfordHealthPlans
JosephCarcioneJr,DO,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademyofNeurology
Disclosure:Nothingtodisclose.
StevenCDronen,MD,FAAEMChair,DepartmentofEmergencyMedicine,LeConteMedicalCenter
StevenCDronen,MD,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicineandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
RagasriKumar,DOResidentPhysician,DepartmentofNeurology,LoyolaUniversityMedicalCenter
Disclosure:Nothingtodisclose.
EdwardAMichelson,MDAssociateProfessor,ProgramDirector,DepartmentofEmergencyMedicine,
UniversityHospitalHealthSystemsinCleveland
EdwardAMichelson,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,NationalAssociationofEMSPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
LoriKSargeant,MDConsultingStaff,SummaEmergencyAssociates,Inc
LoriKSargeant,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
EmergencyPhysicians,andOhioStateMedicalAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1. GoadsbyPJ.Pathophysiologyofclusterheadache:atrigeminalautonomiccephalgia.LancetNeurol.2002
Aug.1(4):2517.[Medline].
2. MatharuM.Clusterheadache.ClinEvid(Online).2010Feb9.2010:[Medline].[FullText].
3. TheInternationalClassificationofHeadacheDisorders:2ndedition.Cephalalgia.2004.24Suppl1:9160.
[Medline].
4. HolleD,ObermannM,KatsaravaZ.Theelectrophysiologyofclusterheadache.CurrPainHeadacheRep.
2009Apr.13(2):1559.[Medline].

http://emedicine.medscape.com/article/1142459clinical#showall

2/3

10/7/2015

ClusterHeadacheClinicalPresentation:History,PhysicalExamination

5. MendizabalJE,UmanaE,ZweiflerRM.Clusterheadache:Horton'scephalalgiarevisited.SouthMedJ.
1998Jul.91(7):60617.[Medline].
6. LodiR,PierangeliG,TononC,etal.StudyofhypothalamicmetabolisminclusterheadachebyprotonMR
spectroscopy.Neurology.2006.66(8):16246.[Medline].
7. KudrowL.Clusterheadache:diagnosisandmanagement.Headache.1979Apr.19(3):14250.[Medline].
8. RozenTD,FishmanRS.FemaleclusterheadacheintheUnitedStatesofAmerica:whatarethegender
differences?ResultsfromtheUnitedStatesClusterHeadacheSurvey.JNeurolSci.2012Jun15.317(1
2):1728.[Medline].
9. PeterlinBL,LevinM,CohenJA,WardTN.Secondaryclusterheadache:apresentationofcerebral
thrombosis.Cephalalgia.2006.26(8):10224.[Medline].
10. RozenTD.Trigeminalautonomiccephalalgias.NeurolClin.2009May.27(2):53756.[Medline].
11. SewellRA.Responseofclusterheadachetokudzu.Headache.2009Jan.49(1):98105.[Medline].
12. [Guideline]EdlowJA,PanagosPD,GodwinSA,ThomasTL,DeckerWW.Clinicalpolicy:criticalissuesin
theevaluationandmanagementofadultpatientspresentingtotheemergencydepartmentwithacute
headache.AnnEmergMed.2008Oct.52(4):40736.[Medline].
13. [Guideline]BiondiD,MendesP.Treatmentofprimaryheadache:clusterheadache.In:Standardsofcare
forheadachediagnosisandtreatment.Chicago(IL):NationalHeadacheFoundation.2004.[FullText].
14. [Guideline]BeithonJ,GallenbergM,JohnsonK,etal.DiagnosisandTreatmentofHeadache.Institutefor
ClinicalSystemsImprovement.Availableathttp://bit.ly/Headache0113.Accessed:March31,2014.
15. CalhounAH,PeterlinBL.Treatmentofclusterheadacheinpregnancyandlactation.CurrPainHeadache
Rep.2010Apr.14(2):16473.[Medline].
16. GiraudP,ChauvetS.Clusterheadacheduringpregnancy:casereportandliteraturereview.Headache.
2009Jan.49(1):1369.[Medline].
17. TfeltHansenP.Acutepharmacotherapyofmigraine,tensiontypeheadache,andclusterheadache.J
HeadachePain.2007Apr.8(2):12734.[Medline].
18. BeckE,SieberWJ,TrejoR.Managementofclusterheadache.AmFamPhysician.2005Feb15.
71(4):71724.[Medline].
19. PagelerL,LimmrothV.Oraltriptansinthepreventivemanagementofclusterheadache.CurrPain
HeadacheRep.2012Apr.16(2):1804.[Medline].
20. StochinoME,DeiddaA,AsuniC,CherchiA,ManchiaM,DelZompoM.Evaluationoflithiumresponsein
episodicclusterheadache:aretrospectivecaseseries.Headache.2012JulAug.52(7):11715.[Medline].
21. KanoH,KondziolkaD,MathieuD,etal.Stereotacticradiosurgeryforintractableclusterheadache:an
initialreportfromtheNorthAmericanGammaKnifeConsortium.JNeurosurg.2011Jun.114(6):173643.
[Medline].
22. AilaniJ,YoungWB.Theroleofnerveblocksandbotulinumtoxininjectionsinthemanagementofcluster
headaches.CurrPainHeadacheRep.2009Apr.13(2):1647.[Medline].
23. GantenbeinAR,LutzNJ,RiedererF,SndorPS.Efficacyandsafetyof121injectionsofthegreater
occipitalnerveinepisodicandchronicclusterheadache.Cephalalgia.2012Jun.32(8):6304.[Medline].
24. FranziniA,FerroliP,LeoneM,BroggiG.Stimulationoftheposteriorhypothalamusfortreatmentof
chronicintractableclusterheadaches:firstreportedseries.Neurosurgery.2003May.52(5):10959
discussion1099101.[Medline].
25. LeoneM,ProiettiCecchiniA,FranziniA,etal.Lessonsfrom8years'experienceofhypothalamic
stimulationinclusterheadache.Cephalalgia.2008Jul.28(7):78797discussion798.[Medline].
26. LeoneM,FranziniA,BroggiG,BussoneG.Hypothalamicstimulationforintractableclusterheadache.
Neurology.2006.67(1):1502.[Medline].
27. MayA,LeoneM.Updateonclusterheadache.CurrOpinNeurol.2003Jun.16(3):33340.[Medline].
28. LeoneM.Deepbrainstimulationinheadache.LancetNeurol.2006Oct.5(10):8737.[Medline].
29. FontaineD,LazorthesY,MertensP,BlondS,GraudG,FabreN.Safetyandefficacyofdeepbrain
stimulationinrefractoryclusterheadache:arandomizedplacebocontrolleddoubleblindtrialfollowedbya
1yearopenextension.JHeadachePain.2010Feb.11(1):2331.[Medline].
30. NarouzeSN.Roleofsphenopalatineganglionneuroablationinthemanagementofclusterheadache.Curr
PainHeadacheRep.2010Apr.14(2):1603.[Medline].
31. NarouzeS,KapuralL,CasanovaJ,MekhailN.Sphenopalatineganglionradiofrequencyablationforthe
managementofchronicclusterheadache.Headache.2009Apr.49(4):5717.[Medline].
32. JrgensTP,GaulC,LindwurmA,etal.Impairmentinepisodicandchronicclusterheadache.Cephalalgia.
2011Apr.31(6):67182.[Medline].
33. RozenTD,FishmanRS.ClusterheadacheintheUnitedStatesofAmerica:demographics,clinical
characteristics,triggers,suicidality,andpersonalburden.Headache.2012Jan.52(1):99113.[Medline].

MedscapeReference2011WebMD,LLC

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