Cluster headaches are often said to be the most painful of all headaches. They have been described as “boring,” " burning," “like a hot poker in the eye,” and as “suicide headaches.” The age of onset of cluster headaches is most often between the ages of 20 and 40, and they are more common in men than women at a ratio of 2:1. For many years, that ratio was stated to be 3:1. Researchers theorize that women have long been misdiagnosed because cluster headaches were thought to be so predominantly found in men.
Cluster Headache Symptoms:
Cluster headaches are attacks of severe pain lasting 15 to 180 minutes and occurring from once every other day up to eight times in one day.
The pain is:
- orbital (near the orbit, the bone framing the eye), supraorbital (above the orbit), temporal (at the temple), or a combination of those sites.
These attacks also include one or more of these symptoms ipsilaterally (on the same side as the pain):
- conjunctival injection
- eyelid edema (swelling)
- forehead and facial sweating
- nasal congestion
Most cluster headache patients are restless or agitated during attacks and find it hard to be still. Cluster sufferers characteristically pace the floor during an attack.
Cluster headaches are diagnosed as “episodic” when the attacks occur in periods lasting seven days to one year, separated by pain-free periods lasting one month or longer. In “chronic” cluster headaches, attacks occur for more than one year without remission or with remissions lasting less than less month.
The term cluster headaches comes from the attacks usually occur in series (cluster periods) lasting for weeks or months separated by remission periods usually lasting months or years. However, about 10–15% of patients have chronic symptoms without remissions.
There are no diagnostic tests to confirm cluster headaches. Diagnosis is accomplished by reviewing the patient’s personal and family medical history, studying their symptoms, and conducting an examination. Cluster headache is then diagnosed by ruling out other causes for the symptoms.
Treatment of Cluster Headaches:
The most commonly used therapies to shorten or abort a cluster attack are:
- 100% oxygen administered by mask
- sumatriptan (Imitrex, Imigran) nasal spray or subcutaneous injection
- DHE-45 subcutaneous injection
The most commonly used preventive medications are:
For consistency in diagnosing and classifying head pain disorders, the _International Headache Society’_s International Classification of Headache Disorders, 3rd Edition (ICHD-3), is generally accepted as the “gold standard.” This provides standardization of diagnoses, providing guidance and reducing confusion.
Information on Cluster Headaches from the ICHD-3:
Previously Used terms:
Ciliary neuralgia; erythro-melalgia of the head; erythroprosopalgia of Bing; hemicrania angioparalytica; hemicrania neuralgiformis chronica; histaminic cephalalgia; Horton’s headache; Harris-Horton’s disease; migrainous neuralgia (of Harris); petrosal neuralgia (of Gardner); Sluder’s neuralgia; spheno-palatine neuralgia; vidian neuralgia
“Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15–180 minutes and occurring from once every other day to eight times a day. The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and/or eyelid oedema, and/or with restlessness or agitation.”
- At least 5 attacks fulfilling criteria B-D
- Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)1
- Either or both of the following:
- at least one of the following symptoms or signs, ipsilateralto the headache:1.conjunctival injection and/or lacrimation2.nasal congestion and/or rhinorrhoea3.eyelid oedema4.forehead and facial sweating5.forehead and facial flushing6.sensation of fullness in the ear7.miosis and/or ptosis2.a sense of restlessness or agitation4.Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active5.Not better accounted for by another ICHD-3 diagnosis.> Note:
1 During part (but less than half) of the time-course of 3.1 Cluster headache, attacks may be less severe and/or of shorter or longer duration.
Attacks occur in series lasting for weeks or months (so-called cluster periods) separated by remission periods usually lasting months or years. About 10–15% of patients have 3.1.2 Chronic cluster headache, without such remission periods. In a large series with good follow-up, one-quarter of patients had only a single cluster period. Such patients meet the criteria for and should be coded as 3.1 Cluster headache.
The pain of 3.1 Cluster headache is maximal orbitally, supraorbitally, temporally or in any combination of these sites, but may spread to other regions. During the worst attacks, the intensity of pain is excruciating. Patients are usually unable to lie down, and characteristically pace the floor. Pain usually recurs on the same side of the head during an individual cluster period. During a cluster period in 3.1.1 Episodic cluster headache, and at any time in 3.1.2 Chronic cluster headache, attacks occur regularly and may be provoked by alcohol, histamine or nitroglycerin.
Age at onset is usually 20–40 years. For unknown reasons, men are afflicted three times more often than women.
Acute attacks involve activation in the region of the posterior hypothalamic grey matter. 3.1 Cluster headache may be autosomal dominant in about 5% of cases. Some patients have been described who have both 3.1 Cluster headache and 13.1 Trigeminal neuralgia (sometimes referred to as cluster-tic syndrome). They should receive both diagnoses. The importance of this observation is that both conditions must be treated for the patient to become headache-free.
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Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd edition (beta version).” Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658.
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_Reviewed by David Watson, MD. _
© Teri Robert, 2009 - Present. • Last updated May 7, 2015.
Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.