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FindArticles / Health / Clinical Psychiatry News / March, 2004

Careful differential diagnosis is

crucial in cluster headache
by Robert Finn

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CANCUN, MEXICO -- A careful differential

More Articles of Interest diagnosis will help distinguish patients with
cluster headache from those with other short-

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the pain can't aid in the diagnosis. Gender ratios provide some clues, since the female-to-male
ratio is 1:3 for cluster headache, 2:1 for paroxysmal hemicrania, and 1:2 for SUNCT.
cluster headache from those with other short-
lasting headaches--a crucial step, because
the treatments for these disorders differ
greatly, Dr. Richard B. Lipton said at a
symposium sponsored by the American
Headache Society.
The first step is to exclude headache
secondary to other causes, such as subdural
hematoma, arterial dissection, or an
intracranial mass, said Dr. Lipton of Albert
Einstein College of Medicine, New York. "If you
see a patient with new-onset cluster
headache, they almost certainly need to be
imaged," because secondary headaches can
signal a medical emergency.
Next, look for autonomic features that point to
one of the three trigeminal autonomic
cephalgias: cluster headache, paroxysmal
hemicrania, and short-lasting, unilateral,
neuralgiform headache with conjunctival
injection and tearing (SUNCT).
All of the trigeminal autonomic cephalgias
have pain localized in V1, the ophthalmic
region of the fifth cranial nerve, so the site of

The trigeminal cephalgias vary as to the frequency and duration of the attacks. Cluster Most Recent Health Articles
headaches tend to occur one to five times a day, although the International Headache Society
(IHS) defines the frequency as 0.5-8 per day. A typical cluster headache lasts 30-90 minutes, National League for Nursing
although the IHS-defined frequency is 15-180 minutes. Online drinking: an exploratory study of
Patients with paroxysmal hemicrania will have five or more headaches per day, each lasting 2- alcohol use and intoxication during
internet activity
30 minutes.
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Patients with SUNCT suffer between 3 and 200 headaches per day, with individual attacks AORN Journal
lasting just 5 seconds to 4 minutes.
Flex
Specific autonomic features also can help differentiate these three conditions. Patients with
SUNCT typically experience both conjunctival injection and lacrimation, but no other autonomic Healthcare Financial Management
symptoms. Patients with paroxysmal hemicrania often have additional autonomic symptoms,
Journal of Family Practice
including nasal congestion, rhinorrhea, eyelid edema, forehead and facial sweating, miosis, and
ptosis.

Patients with cluster headaches may have any of those autonomic symptoms, but also often
experience restlessness and agitation and may have migrainous symptoms, such as nausea,
photophobia, and aura. "This pacing and agitation, this restlessness, is characteristic of cluster
headache," Dr. Lipton said, "and it's a useful differential feature from migraine, where movement
makes pain worse and patients tend to want to hibernate." Content provided in partnership with
A cluster headache attack can be treated acutely, but prophylaxis is the best strategy. "The
problem in treating cluster headache is that the attacks are very brief and very severe, so you
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 need treatment acutely but extremely quickly or else the attack will end before treatment kicks
in," he said.
High-flow 100% oxygen for 15 minutes is highly effective, as is subcutaneous sumatriptan (6
mg), and IV, intramuscular, or subcutaneous dihydroergotamine (0.5-1.0 mg). Zolmitriptan,
ergotamine, and intranasal lidocaine have lower levels of efficacy.

Dr. Lipton regards subcutaneous sumatriptan as the acute treatment of choice, since studies
have shown that it's effective in 90% of patients for 90% of their attacks.

"Because the attacks are frequent and very brief, preventive therapy is the way you want to go,"
he said. "The bottom line is that even if you have somebody who's perfectly responsive to
sumatriptan, that will leave them in agony the 15 minutes a day that they have a daily attack."

Verapamil is best for long-term prophylaxis, but it takes 2 weeks to take effect, so Dr. Lipton
recommends starting a prednisone taper while the verapamil is taking effect. Other agents
effective for preventing cluster headache are lithium carbonate, divalproex sodium, and
methysergide. Methysergide is no longer available in the United States, although it remains
available in Canada. Melatonin, topiramate, and indomethacin have weaker evidence for their
efficacy.
Combination therapy, most commonly lithium plus verapamil, can be tried in patients who are
refractory to single medications. "If cluster is refractory, ... patients become quite impulsive,
agitated, and desperate and sometimes even suicidal, so neglected severe cluster can be
hazardous," Dr. Lipton said. "In general, when things get really out of control a course of
repetitive IV dihydroergotamine, given much as it would be given for chronic migraine, may be
useful."
BY ROBERT FINN
San Francisco Bureau
COPYRIGHT 2004 International Medical News Group
COPYRIGHT 2008 Gale, Cengage Learning

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