Cluster Headache Clinical Presentation_ History, Physical Examination
3
10/7/2015 Cluster Headache Clinical Presentation: History, Physical Examination http://emedicine.medscape.com/article/1142459clinical#showall 1/3 Cluster Headache Clinical Presentation Author: Michelle Blanda, MD; Chief Editor: Tarakad S Ramachandran, MBBS, FRCP, FRCPC more... Updated: Apr 08, 2014 History Attacks of cluster headache (CH) are typically short and occur with a clear periodicity, particularly during sleep or early morning hours, usually corresponding with onset of rapid eye movement (REM) sleep. [5] Unlike migraine, CH is not preceded by aura and is not usually accompanied by symptoms such as nausea, vomiting, photophobia, or osmophobia. Typically, a patient experiences 12 cluster periods per year, each lasting 2 weeks to 3 months. The International Headache Society (IHS) classifies CH as episodic or chronic on the basis of duration as follows [3] : Episodic CH occurs in periods lasting from 7 days to 1 year; cluster attacks are separated by painfree intervals at least 1 month long Chronic CH persists for more than 1 year either without remission or with remissions shorter than 1 month; it is further divided into 2 subcategories, chronic CH from onset and chronic CH evolving from episodic CH The pain of CH is manifested as follows: Character Excruciating, stabbing, sharp, and lancinating (as if the eye is being pushed out), rather than throbbing Location – Unilateral, in the periorbital, retroorbital, or temporal regions, though pain sometimes radiates to the cheek, jaw, occipital, and nuchal regions; the pain tends to remain on the same side during the cluster period but in rare cases may switch sides Distribution First and second divisions of the trigeminal nerve; approximately 1820% of patients complain of pain in the extratrigeminal areas (eg, the back of the neck, along the carotid artery) Onset – Sudden, peaking in 1015 minutes Duration 5 minutes to 3 hours per episode Frequency May occur 18 times a day for as long as 4 months (often nocturnal) Periodicity Circadian regularity in 47% Remission Long symptomfree intervals occur in some patients; the length of these remissions averages 2 years but may range from 2 months to 20 years Pain is accompanied by various cranial parasympathetic symptoms, including the following [5] : Ipsilateral lacrimation (8491%) or conjunctival injection Nasal stuffiness (4875%) or rhinorrhea Ipsilateral eyelid edema Ipsilateral miosis or ptosis Ipsilateral forehead and facial perspiration (26%) Alcoholic products and tobacco may precipitate an attack. Other triggers include hot weather, watching television, nitroglycerin, stress, relaxation, extreme temperatures, glare, allergic rhinitis, and sexual activity. During an attack of CH, as many as 90% of patients may become agitated and extremely restless. They do not like to lie down to rest; instead, they prefer to pace or move around. In desperation, patients may rock, sit, pace, bang themselves against a hard surface, scream in pain, or crawl on the floor. Structural lesions have been described with CH and should be suspected if the presentation is atypical. Atypical features may include the following: Absence of a periodic pattern Residual headache between exacerbations Bilaterality Incomplete or minimal response to standard therapy Presence of lateralizing findings on examination (other than Horner syndrome) Physical Examination Physical examination findings should be normal, except for certain findings that serve as hallmarks of CH. These accompanying findings are consistent with ipsilateral autonomic features characterized by cranial parasympathetic activation and sympathetic hypofunction. The presence of other abnormalities suggests another etiology for the headache. Characteristic findings include the following: Distinctive facial appearance Leonine facies, multifurrowed and thickened skin with prominent folds, a broad chin, vertical forehead creases, and nasal telangiectasias Parasympathetic overactivity Ipsilateral lacrimation, conjunctival injection, rhinorrhea or congestion Ocular sympathetic paralysis Mild Horner syndrome (eg, ptosis, miosis, and anhidrosis), which may persist between attacks
-
Upload
michael-hostiadi -
Category
Documents
-
view
7 -
download
1
description
CH
Transcript of Cluster Headache Clinical Presentation_ History, Physical Examination
10/7/2015 Cluster Headache Clinical Presentation: History, Physical Examination
http://emedicine.medscape.com/article/1142459clinical#showall 1/3
Cluster Headache Clinical PresentationAuthor: Michelle Blanda, MD; Chief Editor: Tarakad S Ramachandran, MBBS, FRCP, FRCPC more...
Updated: Apr 08, 2014
HistoryAttacks of cluster headache (CH) are typically short and occur with a clearperiodicity, particularly during sleep or early morning hours, usually correspondingwith onset of rapid eye movement (REM) sleep.[5] Unlike migraine, CH is notpreceded by aura and is not usually accompanied by symptoms such as nausea,vomiting, photophobia, or osmophobia. Typically, a patient experiences 12 clusterperiods per year, each lasting 2 weeks to 3 months.
The International Headache Society (IHS) classifies CH as episodic or chronic onthe basis of duration as follows[3] :
Episodic CH occurs in periods lasting from 7 days to 1 year; cluster attacksare separated by painfree intervals at least 1 month longChronic CH persists for more than 1 year either without remission or withremissions shorter than 1 month; it is further divided into 2 subcategories,chronic CH from onset and chronic CH evolving from episodic CH
The pain of CH is manifested as follows:
Character Excruciating, stabbing, sharp, and lancinating (as if the eye isbeing pushed out), rather than throbbingLocation – Unilateral, in the periorbital, retroorbital, or temporal regions,though pain sometimes radiates to the cheek, jaw, occipital, and nuchalregions; the pain tends to remain on the same side during the cluster periodbut in rare cases may switch sidesDistribution First and second divisions of the trigeminal nerve;approximately 1820% of patients complain of pain in the extratrigeminalareas (eg, the back of the neck, along the carotid artery)Onset – Sudden, peaking in 1015 minutesDuration 5 minutes to 3 hours per episodeFrequency May occur 18 times a day for as long as 4 months (oftennocturnal)Periodicity Circadian regularity in 47%Remission Long symptomfree intervals occur in some patients; the lengthof these remissions averages 2 years but may range from 2 months to 20years
Pain is accompanied by various cranial parasympathetic symptoms, including thefollowing[5] :
Ipsilateral lacrimation (8491%) or conjunctival injectionNasal stuffiness (4875%) or rhinorrheaIpsilateral eyelid edemaIpsilateral miosis or ptosisIpsilateral forehead and facial perspiration (26%)
Alcoholic products and tobacco may precipitate an attack. Other triggers include hotweather, watching television, nitroglycerin, stress, relaxation, extreme temperatures,glare, allergic rhinitis, and sexual activity.
During an attack of CH, as many as 90% of patients may become agitated andextremely restless. They do not like to lie down to rest; instead, they prefer to paceor move around. In desperation, patients may rock, sit, pace, bang themselvesagainst a hard surface, scream in pain, or crawl on the floor.
Structural lesions have been described with CH and should be suspected if thepresentation is atypical. Atypical features may include the following:
Absence of a periodic patternResidual headache between exacerbationsBilateralityIncomplete or minimal response to standard therapyPresence of lateralizing findings on examination (other than Hornersyndrome)
Physical ExaminationPhysical examination findings should be normal, except for certain findings thatserve as hallmarks of CH. These accompanying findings are consistent withipsilateral autonomic features characterized by cranial parasympathetic activationand sympathetic hypofunction. The presence of other abnormalities suggestsanother etiology for the headache.
Characteristic findings include the following:
Distinctive facial appearance Leonine facies, multifurrowed and thickenedskin with prominent folds, a broad chin, vertical forehead creases, and nasaltelangiectasiasParasympathetic overactivity Ipsilateral lacrimation, conjunctival injection,rhinorrhea or congestionOcular sympathetic paralysis Mild Horner syndrome (eg, ptosis, miosis, andanhidrosis), which may persist between attacks
10/7/2015 Cluster Headache Clinical Presentation: History, Physical Examination
http://emedicine.medscape.com/article/1142459clinical#showall 2/3
BradycardiaFacial flushing or pallorScalp and facial tendernessIpsilateral carotid tenderness (in some patients)
Patients often are in severe distress. They may lower the head and press on thesite of pain, sometimes crying or screaming. Physical exercise may afford a degreeof relief. In cases of especially severe or intolerable pain, patients may eventhreaten suicide.
Differential Diagnoses
Contributor Information and DisclosuresAuthorMichelle Blanda, MD Chair Emeritus, Department of Emergency Medicine, Summa Health System AkronCity/St Thomas Hospital; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Michelle Blanda, MD is a member of the following medical societies: American College of EmergencyPhysicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Coauthor(s)Rima M Dafer, MD, MPH, FAHA Associate Professor, Department of Neurology and Neurological Surgery,Loyola University, Chicago Stritch School of Medicine
Rima M Dafer, MD, MPH, FAHA is a member of the following medical societies: American Academy ofNeurology, American Heart Association, American Headache Society
Disclosure: Nothing to disclose.
Chief EditorTarakad S Ramachandran, MBBS, FRCP, FRCPC Professor Emeritus of Neurology and Psychiatry, ClinicalProfessor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State Universityof New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse IrvingMemorial Hospital
Tarakad S Ramachandran, MBBS, FRCP, FRCPC is a member of the following medical societies: AmericanCollege of International Physicians, American Heart Association, American Stroke Association, AmericanAcademy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute,National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians,Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society ofMedicine
Disclosure: Nothing to disclose.
AcknowledgementsJoseph Carcione Jr, DO, MBA Consultant in Neurology and Medical Acupuncture, Medical Management andOrganizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans
Joseph Carcione Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.
Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy ofEmergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Ragasri Kumar, DO Resident Physician, Department of Neurology, Loyola University Medical Center
Disclosure: Nothing to disclose.
Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine,University Hospital Health Systems in Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of EmergencyPhysicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Lori K Sargeant, MD Consulting Staff, Summa Emergency Associates, Inc
Lori K Sargeant, MD is a member of the following medical societies: Alpha Omega Alpha, American College ofEmergency Physicians, and Ohio State Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; EditorinChief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
References
1. Goadsby PJ. Pathophysiology of cluster headache: a trigeminal autonomic cephalgia. Lancet Neurol. 2002Aug. 1(4):2517. [Medline].
2. Matharu M. Cluster headache. Clin Evid (Online). 2010 Feb 9. 2010:[Medline]. [Full Text].
3. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004. 24 Suppl 1:9160.[Medline].
4. Holle D, Obermann M, Katsarava Z. The electrophysiology of cluster headache. Curr Pain Headache Rep.2009 Apr. 13(2):1559. [Medline].
10/7/2015 Cluster Headache Clinical Presentation: History, Physical Examination
http://emedicine.medscape.com/article/1142459clinical#showall 3/3
Medscape Reference © 2011 WebMD, LLC
5. Mendizabal JE, Umana E, Zweifler RM. Cluster headache: Horton's cephalalgia revisited. South Med J.1998 Jul. 91(7):60617. [Medline].
6. Lodi R, Pierangeli G, Tonon C, et al. Study of hypothalamic metabolism in cluster headache by proton MRspectroscopy. Neurology. 2006. 66(8):16246. [Medline].
7. Kudrow L. Cluster headache: diagnosis and management. Headache. 1979 Apr. 19(3):14250. [Medline].
8. Rozen TD, Fishman RS. Female cluster headache in the United States of America: what are the genderdifferences? Results from the United States Cluster Headache Survey. J Neurol Sci. 2012 Jun 15. 317(12):1728. [Medline].
9. Peterlin BL, Levin M, Cohen JA, Ward TN. Secondary cluster headache: a presentation of cerebralthrombosis. Cephalalgia. 2006. 26(8):10224. [Medline].
10. Rozen TD. Trigeminal autonomic cephalalgias. Neurol Clin. 2009 May. 27(2):53756. [Medline].
11. Sewell RA. Response of cluster headache to kudzu. Headache. 2009 Jan. 49(1):98105. [Medline].
12. [Guideline] Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: critical issues inthe evaluation and management of adult patients presenting to the emergency department with acuteheadache. Ann Emerg Med. 2008 Oct. 52(4):40736. [Medline].
13. [Guideline] Biondi D, Mendes P. Treatment of primary headache: cluster headache. In: Standards of carefor headache diagnosis and treatment. Chicago (IL): National Headache Foundation. 2004. [Full Text].
14. [Guideline] Beithon J, Gallenberg M, Johnson K, et al. Diagnosis and Treatment of Headache. Institute forClinical Systems Improvement. Available at http://bit.ly/Headache0113. Accessed: March 31, 2014.
15. Calhoun AH, Peterlin BL. Treatment of cluster headache in pregnancy and lactation. Curr Pain HeadacheRep. 2010 Apr. 14(2):16473. [Medline].
16. Giraud P, Chauvet S. Cluster headache during pregnancy: case report and literature review. Headache.2009 Jan. 49(1):1369. [Medline].
17. TfeltHansen P. Acute pharmacotherapy of migraine, tensiontype headache, and cluster headache. JHeadache Pain. 2007 Apr. 8(2):12734. [Medline].
18. Beck E, Sieber WJ, Trejo R. Management of cluster headache. Am Fam Physician. 2005 Feb 15.71(4):71724. [Medline].
19. Pageler L, Limmroth V. Oral triptans in the preventive management of cluster headache. Curr PainHeadache Rep. 2012 Apr. 16(2):1804. [Medline].
20. Stochino ME, Deidda A, Asuni C, Cherchi A, Manchia M, Del Zompo M. Evaluation of lithium response inepisodic cluster headache: a retrospective case series. Headache. 2012 JulAug. 52(7):11715. [Medline].
21. Kano H, Kondziolka D, Mathieu D, et al. Stereotactic radiosurgery for intractable cluster headache: aninitial report from the North American Gamma Knife Consortium. J Neurosurg. 2011 Jun. 114(6):173643.[Medline].
22. Ailani J, Young WB. The role of nerve blocks and botulinum toxin injections in the management of clusterheadaches. Curr Pain Headache Rep. 2009 Apr. 13(2):1647. [Medline].
23. Gantenbein AR, Lutz NJ, Riederer F, Sándor PS. Efficacy and safety of 121 injections of the greateroccipital nerve in episodic and chronic cluster headache. Cephalalgia. 2012 Jun. 32(8):6304. [Medline].
24. Franzini A, Ferroli P, Leone M, Broggi G. Stimulation of the posterior hypothalamus for treatment ofchronic intractable cluster headaches: first reported series. Neurosurgery. 2003 May. 52(5):10959;discussion 1099101. [Medline].
25. Leone M, Proietti Cecchini A, Franzini A, et al. Lessons from 8 years' experience of hypothalamicstimulation in cluster headache. Cephalalgia. 2008 Jul. 28(7):78797; discussion 798. [Medline].
26. Leone M, Franzini A, Broggi G, Bussone G. Hypothalamic stimulation for intractable cluster headache.Neurology. 2006. 67(1):1502. [Medline].
27. May A, Leone M. Update on cluster headache. Curr Opin Neurol. 2003 Jun. 16(3):33340. [Medline].
28. Leone M. Deep brain stimulation in headache. Lancet Neurol. 2006 Oct. 5(10):8737. [Medline].
29. Fontaine D, Lazorthes Y, Mertens P, Blond S, Géraud G, Fabre N. Safety and efficacy of deep brainstimulation in refractory cluster headache: a randomized placebocontrolled doubleblind trial followed by a1year open extension. J Headache Pain. 2010 Feb. 11(1):2331. [Medline].
30. Narouze SN. Role of sphenopalatine ganglion neuroablation in the management of cluster headache. CurrPain Headache Rep. 2010 Apr. 14(2):1603. [Medline].
31. Narouze S, Kapural L, Casanova J, Mekhail N. Sphenopalatine ganglion radiofrequency ablation for themanagement of chronic cluster headache. Headache. 2009 Apr. 49(4):5717. [Medline].
32. Jürgens TP, Gaul C, Lindwurm A, et al. Impairment in episodic and chronic cluster headache. Cephalalgia.2011 Apr. 31(6):67182. [Medline].
33. Rozen TD, Fishman RS. Cluster headache in the United States of America: demographics, clinicalcharacteristics, triggers, suicidality, and personal burden. Headache. 2012 Jan. 52(1):99113. [Medline].
