Cluster headache sufferers typically experience very severe headaches of a piercing quality near one eye or temple that last for between 15 minutes and three hours. The headaches are unilateral and occasionally change sides.

Cluster headaches are frequently associated with drooping eyelids, conjunctival injection (which results in red, watery eyes), tearing, constricted pupil, eyelid edema, nasal congestion, runny nose, and sweating on the affected side of the face. The neck is often stiff or tender in association with cluster headaches, and jaw and teeth pain is sometimes reported.

During an attack, the person often is unable to be still and may pace. Sensitivity to light is more typical of a migraine, as is vomiting, but they can be present in some sufferers of cluster headache.

In episodic cluster headache, these attacks occur once or more daily, often at the same times each day, for a period of several weeks, followed by a headache-free period lasting weeks, months, or even years. Approximately 10-15% of cluster headache sufferers are chronic; they can experience multiple headaches every day for years.

Cluster headaches are occasionally referred to as "alarm clock headaches", as they can occur at night and wake a person from sleep at the same time each night or at a certain period after falling asleep. Other synonyms for cluster headache include Horton's syndrome and "suicide headaches" (a reference to the excruciating pain and resulting desperation).

The location and type of pain has been compared to a "brain-freeze" headache from rapidly eating ice cream; this analogy is limited, but may offer some insight into the cluster headache experience. Persons who have experienced both cluster headaches and other painful conditions (childbirth, migraines) report that the pain of cluster headaches is far worse. One analogy is that of a burning ice pick being repeatedly stabbed through the eye into the brain.

Incidence

Whereas other headaches, such as migraines are diagnosed more often in women, cluster headaches are diagnosed in men at a rate 2.5 to 3 times greater than in women. Between 1 and 4 people per thousand experience cluster headaches in the U.S. and Western Europe; statistics for other parts of the world are fragmentary. Latitude plays a role in the occurrence of cluster headaches, which are more common as one moves away from the equator towards the poles. It is believed that greater changes in day length are responsible for the increase.

Pathology

While the immediate cause of pain is in the trigeminal nerve, the true cause(s) of cluster headache is complex and not fully understood. Cluster headaches are a type of vascular headache and the intense pain of an attack is also associated with the dilation of blood vessels.

Definition

Cluster headaches are characterized by an intense one-sided pain centered by the eye or temple. The pain lasts for one to two hours on average and may recur several times in a day.

Description

Cluster headaches have been known as histamine headaches, red migraines, and Horton's disease, among others. The constant factor is the pain, which transcends by far the distress of the more common tension-type headache or even that of a migraine headache.

Cluster headaches afflict less than 0.5% of the population and predominantly affect men; approximately 80% of sufferers are male. Onset typically occurs in the late 20s, but there is no absolute age restriction. Approximately 80% of cluster headaches are classified as episodic; the remaining 20% are considered chronic. Both display the same symptoms. However, episodic cluster headaches occur during 1- to 5-month periods followed by 6- to 24-month attack-free, or remission, periods. There is no such reprieve for chronic cluster headache sufferers.

Causes & symptoms

Biochemical, hormonal, and vascular changes induce cluster headaches, but why these changes occur remains unclear. Episodic cluster headaches seem to be linked to changes in day length, possibly signaling a connection to the so-called biological clock. Alcohol, tobacco, histamine, or stress can trigger cluster headaches. Decreased blood oxygen levels (hypoxemia) can also act as a trigger, particularly during the night when an individual is sleeping. Interestingly, the triggers do not cause cluster headaches during remission periods.

The primary cluster headache symptom is excruciating one-sided head pain centered behind an eye or near the temple. This pain may radiate outward from the initial focus and encompass the mouth and teeth. For this reason, some cluster headache sufferers may mistakenly attribute their pain to a dental problem. Secondary symptoms, occurring on the same side as the pain, include eye tearing, nasal congestion followed by a runny nose, pupil contraction, and facial drooping or flushing.

Diagnosis

Cluster headache symptoms guide the diagnosis. A medical examination includes recording headache details, such as frequency and duration, when it occurs, pain intensity and location, possible triggers, and any prior symptoms. This history allows other potential problems to be discounted.

Treatment

Treatment for cluster headaches is composed of induction, maintenance, and symptomatic therapies. The first two therapies are prophylactic treatments, geared toward preventing headaches. Symptomatic therapy is meant to stop or shorten a headache.

Induction and maintenance therapies begin together. Induction therapy is intended to break the headache cycle with drugs such as corticosteroids (for example, prednisone) or dihydroergotamine. These drugs are not meant for long-term therapy, but rather as a jump-start formaintenance therapy. Maintenance therapy drugs include verapamil, lithium carbonate, ergotamine, and methysergide. These drugs have long-term effectiveness, but must be taken for at least a week before a response is observed. With long-tern treatment, methysergide must be stopped for one month each year to avoid dangerous side effects (formation of fibrous tissue inside the abdominal artery, lungs, and heart valves).

Despite prophylactic treatment, headaches may still occur. Symptomatic therapy includes oxygen inhalation, sumatriptan injection, and application of local anesthetics inside the nose. Surgery is a last resort for chronic cluster headaches that fail to respond to therapy.

Alternative treatment

Since some cluster headaches are triggered by stress, stress reduction techniques, such as yoga, meditation, and regular exercise, may be effective. Some cluster headaches may be an allergic response triggered by food or environmental substances, therefore identifying and removing the allergen(s) may be key to resolution of the problem. Histamine is another suspected trigger of cluster headaches, and this response may be controlled with vitamin C and the bioflavonoids quercetin and bromelain (pineapple enzyme). Supplementation with essential fatty acids (EFA) will help decrease any inflammatory response.

Physical medicine therapies such as adjustments of the spine, craniosacral treatment, and massage at the temporomandibular joint (TMJ) can clear blockages, as can traditional Chinese medical therapies including acupuncture. Homeopathic treatment can also be beneficial. Nervous system relaxant herbs, used singly or in combination, can allow the central nervous system to relax as well as assist in peripheral nerve response. A few herbs to consider for relaxation are valerian (Valeriana officinalis), chamomile (Matricaria recutita), rosemary (Rosemarinus officinalis), and skullcap (Scutellaria baicalensis).

Prognosis

In general, drug therapy offers effective treatment.

Prevention

Avoiding triggers, adhering to medical treatment, and controlling stress can help ward off some cluster headaches.

Key Terms

Biological clock: A synonym for the body's circadian rhythm, the natural biological variations that occur over the course of a day.
Migraine headache: An intense throbbing pain that occurs on one or both sides of the head. The headache is usually accompanied by other symptoms, such as nausea, vomiting, and aversion to light.
Prophylactic: Referring to treatment that prevents symptoms from occurring.
Tension-type headache: A dull pain that seems to exert pressure on the head; the most common form of headache.

For Your Information

Periodicals

Diamond, Seymour. "Cluster Headache: How to Distinguish from Migraine." Consultant, 36 (7)(1996): 1449.
Lewis, Todd A., and Glen D. Solomon. "Advances in Cluster Headache Management." Cleveland Clinic Journal of Medicine, 63 (4)(1996): 237.
Organizations
American Council for Headache Education. 19 Mantua Road, Mt. Royal, NJ 08061. (609) 423-0043. (800) 255-2243. http://www.achenet.org/.
National Headache Foundation. 428 West St. James Place, Chicago, IL 60614. (773) 388-6399. (800) 843-2256. http://www.headaches.org/.

Gale Encyclopedia of Medicine. Gale Research, 1999.

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