Neuroscience · Year 2 · from Neuroscience
Case 2: Cluster Headache
Patient Presentation
Demographics: 42-year-old male
Chief Complaint: Severe headaches around his right eye occurring nightly for 3 weeks
History of Present Illness: For the past 3 weeks, the patient has been awakened from sleep almost every night between 2-3 AM by an excruciating pain centered around and behind his right eye. He describes the pain as "boring" and "like a hot poker in my eye." The pain reaches maximum intensity within 5 minutes and is rated 10/10 - the worst pain he has ever experienced. During attacks, his right eye becomes red and tears profusely, his right nostril runs, and he feels extremely restless - he cannot lie still and paces around his bedroom. Each episode lasts approximately 60-90 minutes then resolves completely. He has had 1-2 attacks per day, usually including one nocturnal attack and sometimes one in the late afternoon. He recalls having a similar "cluster" of headaches 2 years ago that lasted about 6 weeks and then resolved.
Observed During Attack in ED:
- Patient pacing, unable to sit still
- Holding right side of head
- Right eye: conjunctival injection (red), lacrimation (tearing), eyelid swelling
- Right pupil: slightly smaller than left (miosis)
- Right nostril: rhinorrhea
Physical Examination (between attacks):
- Vital signs: BP 132/82, HR 74, T 36.9C
- General: Appears tired but comfortable
- Neurological examination: Completely normal including pupils equal, no residual autonomic signs
Diagnosis: Episodic cluster headache
Treatment:
Acute Treatment:
- High-flow oxygen therapy: 100% O2 at 12-15 L/min via non-rebreather mask for 15-20 minutes at attack onset
- Sumatriptan 6 mg subcutaneous injection (for attacks unresponsive to oxygen)
Transitional/Bridge Therapy:
- Prednisone 60 mg daily for 5 days, then taper over 2 weeks (rapid suppression of attacks while preventive takes effect)
Preventive Treatment:
- Verapamil 80 mg three times daily, titrate to 240 mg three times daily
- ECG monitoring (verapamil can cause heart block at high doses)
Lifestyle:
- Avoid alcohol during cluster period (known trigger)
- Maintain regular sleep schedule
Clinical Course: Oxygen therapy aborted most attacks within 10-15 minutes. The prednisone burst rapidly reduced attack frequency. After verapamil reached therapeutic dose, attacks decreased to occasional mild episodes. The cluster period ended after 8 weeks total. The patient was educated about the likely recurrence in the future and maintained oxygen equipment at home.
Clinical Pearl: Cluster headache is characterized by severe unilateral periorbital pain with ipsilateral autonomic features (conjunctival injection, lacrimation, nasal congestion/rhinorrhea, forehead sweating, miosis, ptosis, eyelid edema). Unlike migraine patients who lie still in dark rooms, cluster patients are agitated and restless during attacks. The attacks have remarkable periodicity - occurring at the same time daily, often awakening patients from sleep. High-flow oxygen is first-line abortive therapy and is effective in approximately 70% of patients within 15 minutes.