Definition and symptoms

According to the International Headache Classification of Headache, 2 types are found:

• Episodic (at least 2 cluster periods lasting 3 to 365 days and separated by pain free remission periods of more than 1 month)

Chronic (attacks recur over 1 year without remission periods lasting less than 1 month). Recurrent attack cycles, lasting from 2 weeks to 3 months. Attacks range from 8 per day to one every second day. Severe (most severe) pain (drilling or boring) occurring unilaterally in the orbital or temporal regions. The pain is unilateral during an attack and rarely shifts sides from cycle to Individual attacks last from 15 to 180 minutes in duration. The hallmark of cluster is the association of prominent cranial parasympathetic autonomic features that include lacrimation, conjunctival injection, nasal congestion, rhinorrhoea, eye lid swelling, facial sweating, miosis and ptosis, ipsilateral to the pain. During an attack the patient is restless and agitated

Aetiology

• • Men are 4 times more prone than women
  • Age: 20-50 years (but can be as young as 10 years depending on associated disorders or family history).
  • High level of disability due to multiple daily attacks of severe pain, many of which occur and disrupt sleep.
  • Pathophysiology of cluster headaches is not well understood
  • Abnormalities of the hypothalamus have been implicated, may explain occurrence during change of season and waking during sleep (circadian rhythm)
  • There are descending fibres from the hypothalamus to the trigeminal nucleus caudalis and the superior salivary nucleus which could activate the trigeminovascular system and cranial parasympathetic system, resulting in the clinical signs and symptoms such as pain and autonomic
  • Abnormal levels of cortisol, growth hormone, testosterone and melatonin are found during cluster headaches and remission periods.
  • Nitric oxide/nitrates/nitroglycerine has been shown to trigger cluster headaches. It may be an intermediate neurotransmitter which may stimulate vasodilation resulting in the intense pulsating pain
  • May be triggered by alcohol while in an attack cycle
  • Other triggers may include: stress, glare or bright lights, allergies,
  • Increased incidence of peptic ulcer and coronary heart disease has been noted with male patients; may be genetic predisposition

Signs

• • Abnormal head posture and hypertonic muscles
  • Hypertonic and tender cervical and/or facial muscles
  • Decreased cervical spine range of motion
  • Cervical joint dysfunction

Management

• • Cervical spine (upper) and occiput manipulation
  • Mobilisation of cervical and thoracic spine
  • Cervical spine traction
  • Soft tissue massage
  • Dry needling and ischemic compression of surrounding muscles (trapezius, levator scapulae, posterior cervical, suboccipital, SCM, splenius)
  • Stretching
  • Ergonomics and postural and trigger advice

Treatment (If conservative management fails)

• • 100% oxygen therapy, sumatriptanin (nasal or subcutaneous injection form), ergotamine (range of forms) are used as abortive agents.
  • Steroids such as prednisone, verapamil and ithium may be used as
  • Anti-epileptics or calcium channel blockers may be used in the prevention of cluster headache
  • Abortive agents work at both the trigeminal level and

Prognosis

• • 80% of patients with the episodic variant tend to maintain the episodic form; some may transform into chronic cluster headache. Chronic cluster headache is more relentless.