Neurology · Year 3 · from Neurology

Case 2: Cluster Headache

Patient Demographics

  • Age: 35 years
  • Sex: Male
  • Occupation: Electrician

Chief Complaint

"I get the worst pain of my life behind my right eye - it makes me want to bang my head against the wall."

History of Present Illness

For the past 3 weeks, the patient has been experiencing excruciating headaches centered around his right eye. The pain comes suddenly, reaching peak intensity within 5-10 minutes, and lasts 45-90 minutes. During attacks, his right eye becomes red and teary, his right nostril is congested then runny, and his right eyelid droops. The attacks occur 2-3 times daily, often waking him from sleep at the same time each night (around 2 AM). He is unable to lie still during attacks - he paces, rocks, or hits his head. He denies nausea but cannot eat during attacks due to severity. He experienced similar episodes last spring that lasted 6 weeks then completely resolved.

Neurological Examination Findings

Between Attacks:

  • Mental status: Normal
  • Cranial nerves: II-XII intact, no ptosis currently
  • Motor: 5/5 throughout
  • Sensory: Intact
  • Reflexes: 2+ symmetric
  • Coordination and gait: Normal

During Attack (observed in ED):

  • Severe agitation, unable to sit still, pacing
  • Right eye: Conjunctival injection, lacrimation
  • Right nostril: Clear rhinorrhea
  • Right eyelid: Partial ptosis
  • Right pupil: Slightly miotic compared to left
  • Patient rating pain 10/10

Diagnostic Criteria Applied

ICHD-3 Criteria for Cluster Headache:

  • At least 5 attacks fulfilling criteria B-D (YES)
  • Severe unilateral orbital/supraorbital/temporal pain lasting 15-180 min (YES - 45-90 min)
  • Either or both: ipsilateral autonomic symptoms (YES - all present) or restlessness/agitation (YES)
  • Attack frequency: 1 to 8 per day (YES - 2-3/day)
  • Not better accounted for by another diagnosis

Episodic vs Chronic: Episodic (remission periods of ≥3 months)

Neuro Workup

  • MRI Brain with and without contrast: Normal, no pituitary lesion
  • MRA Head: No aneurysm or vascular abnormality
  • Imaging indicated: First cluster presentation to exclude secondary causes (pituitary tumor, cavernous sinus lesion, arterial dissection)

Diagnosis

Episodic cluster headache (right-sided)

Management

Acute Treatment:

  1. First-line: High-flow oxygen 100% via non-rebreather mask at 12-15 L/min for 15-20 minutes (keep at home)
  2. First-line: Sumatriptan 6 mg subcutaneous injection (maximum 2/day)
  3. Alternative: Zolmitriptan 5 mg nasal spray
  4. Avoid oral triptans (too slow onset)

Transitional Prophylaxis (Bridge Therapy):

  1. Prednisone 60-80 mg daily for 5 days, then taper over 2-3 weeks
  2. Or occipital nerve block (greater occipital nerve)

Preventive Treatment (for cluster period):

  1. Verapamil 80 mg TID, titrate to 240-480 mg/day (monitor ECG for heart block)
  2. Alternatives: Lithium, topiramate, melatonin

Lifestyle:

  1. Avoid alcohol during cluster period (potent trigger)
  2. Avoid afternoon naps
  3. Maintain regular sleep schedule
  4. No smoking (theoretical trigger)

Clinical Image

Image Description: Clinical photograph demonstrating the autonomic features of cluster headache during an attack: conjunctival injection, lacrimation, and partial ptosis of the right eye.

Attribution: Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Cluster_headache.jpg

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