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

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