Headache Disease

BASICS

DESCRIPTION

Attacks of severe, unilateral headache typically localized in periorbital area and temple associated with ipsilateral lacrimation, rhinorrhea, ptosis, miosis, and nasal congestion. Individual attacks last 30-180 minutes and occur 1-6 times per day. Two forms exist: episodic with attack phases lasting 4-16 weeks, followed by a cluster-free interval of generally 6 months to years duration; and chronic, with a cluster-free interval of less than 1 week in a 12 month period of time.

System(s) affected: Nervous
Genetics: Unknown
Incidence/Prevalence in USA: 0.5-1% of adult population
Predominant age: Mean age of onset: 30 years in men, later in women
Predominant sex: Male > Female (6:1)

SIGNS AND SYMPTOMS

Sudden onset of severe headache
Headache reaches crescendo within 15 minutes, lasts < 3 hours
Pain is unilateral, oculotemporal or oculofrontal; rare in other locations
Severe, piercing, boring, exploding, penetrating (occasionally throbbing) pain
Ipsilateral partial Horner's syndrome (ptosis and miosis)
Lacrimation (84%)
Injected conjunctiva (58%)
Ptosis (57%)
Nasal stuffiness (48%)
Rhinorrhea (43%)
Bradycardia (43%)
Nausea (40%)
Perspiration (26%)
Restlessness and agitation during attacks
Attacks may occur at same time for consecutive days; frequently an attack occurs within 90 minutes of falling to sleep (corresponding to first REM sleep)

CAUSES

Unknown, perhaps:

Disruption of circadian rhythm based on hypothalamus
Disturbed autoregulation of cerebral arteries
Disorder of serotonin metabolism or transmission in CNS
Disorder of histamine concentrations or receptors

RISK FACTORS

Male gender
Age > 30 years
Small amounts of vasodilators, such as alcohol or nitroglycerin
Occasional relationship to previous head trauma or surgery

DIAGNOSIS

LABORATORY

Not useful except to rule out differential diagnosis

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

N/A

IMAGING

Generally of little value except in atypical presentations or those unresponsive to therapy

DIAGNOSTIC PROCEDURES

N/A

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient except in patient at suicidal risk

GENERAL MEASURES

During cluster periods, avoid alcohol, bright lights and glare, excessive emotion and stress as these may precipitate attacks
Avoid narcotic analgesics, especially oral preparations
Tobacco (high predilection for tobacco abuse in this population) may make patients more refractory to therapy

SURGICAL MEASURES

Radiofrequency trigeminal gangliolysis in carefully selected refractory patients with strictly unilateral attacks

ACTIVITY

Avoid self-injury during bouts of excruciating pain
Vigorous physical activity at first symptom may abort attack in some
Compression of ipsilateral carotid or temporal artery may reduce pain in some. Caution exercised in recommending carotid massage in patient at risk for occult carotid disease.

DIET

During cluster phase, alcohol even in small amounts frequently precipitates attacks
Rarely, specific foods may trigger attacks

PATIENT EDUCATION

Focus on the validity, natural history, and pathology of the condition
Advise patient to avoid known precipitants
Assist patient with learning self-treatment methods
Provide supportive relationship and follow-up
Avoid high altitudes

FOLLOW UP

PREVENTION/AVOIDANCE

Alcohol, nitroglycerine, and some foods can induce cluster attack
Disturbances in sleep cycle can induce attacks (sleep cycle disruption common due to anticipation and occurrence of nocturnal attacks)
Strong emotions, anger, excessive physical activity may induce attacks
Tobacco may slow responsiveness to medication
Narcotics may expedite transformation of episodic cluster to chronic cluster

POSSIBLE COMPLICATIONS

Self-injury during attack
Side-effects of medication including unmasking of coronary heart disease
Potential for drug abuse

EXPECTED COURSE AND PROGNOSIS

Recurrent attacks
Prolonged remissions
Possibility of transformation of episodic cluster to chronic cluster and occasionally chronic cluster to episodic cluster

MISCELLANEOUS

ASSOCIATED CONDITIONS

Significantly higher incidence of peptic ulcer and coronary heart disease (males)
Prior history of migraine frequently in female patients
Increased risk of suicide

AGE-RELATED FACTORS

Pediatric: Very rare cases reported
Geriatric: N/A
Others:

With age - more likely to begin in women, often in peri- or post-menopausal years
Characteristic appearance - "leonine" face, thickened skin, above average height, more likely to have hazel eye color, and be heavy smokers. No evidence of specific psychologic type.

PREGNANCY

Very rare in pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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