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Cluster Headache Often Mistaken
for Nasal, Sinus, or Ocular Condition |
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BY DON SCHRADER
Contributing Writer |
SCOTTSDALE, ARIZ. (ECCC)—
Nasal and ocular symptoms associated with cluster headache can
easily lead a clinician down the wrong diagnostic pathway, said
Dr. Frederick G. Freitag on February 21 at a headache course
sponsored by the Diamond Headache Clinic Research and Education
Foundation.
Droopy eyelid, tearing, nasal congestion, and even perfuse
rhinorrhea can occur in patients with cluster headache.
“This constellation of nasal-eye symptoms plays a role, I
believe, in some of the misdiagnosis and maldiagnosis of cluster
headache, particularly when those symptoms are combined with the
seasonal occurrence that is typical of cluster headache,” said
Dr. Freitag, associate director of the Diamond Headache Clinic
in Chicago.
“If a patient with headache presents in the fall of the year and
complains of stuffiness, the nose runs, and the eyes are red. A
physician could understandably think ‘This could be allergies or
sinus problems.’”
The misdiangosis can lead to inappropriate treatment that
ironically may provide some transient benefits, Dr. Freitag
continued. Because decongestants constrict blood vessels, they
relieve the headache and associated symptoms for awhile. Then
the headaches resume and the patient continues with
misdiagnosis.
“The point is that we need to pay attention to the whole
constellation of symptoms and perform a thorough history and
physical examination,” said Dr. Freitag.
The ocular signs and symptoms of cluster headache can include
eyelid and pupil symptoms that mimic Horner’s syndrome, he
added. The eye on the same side of the head affected by the
headache pain may become droopy. The headache pain may
concentrate in the orbital area around the eye, and some
patients complain of residual soreness in and around the orbital
area after resolution of the headache.
The epidemiology of cluster headache has changed in recent
years. Once considered a condition affecting men almost
exclusively, cluster headache has begun to occur in more women,
said Dr. Freitag. Multiple medical and nonmedical explanations
have been offered for the increased number of women affected by
the condition, but better recognition and diagnosis of cluster
headache by clinicians probably has played a major role, he
added.
Other features of the condition largely remain the same. Cluster
headache tends to have an onset in a person’s late 20s or early
30s. Most patients have one or two cycles per year, lasting 2 to
3 months. Spontaneous remissions do occur and last an average of
about 2 years, although a range of 2 months to 20 years has been
reported.
Two common periods of onset are within the first 2 weeks before
or after the summer and winter solstices, according to Dr.
Freitag. In many patients, cluster headache has a circadian
pattern of onset. Attacks often occur at night, especially near
the end of a sleep cycle.
As opposed to the throbbing pain that typifies migraine, cluster
headache involves localized pain that patients describe as a
deep burning or boring sensation. Migrainous features, such as
nausea and vomiting, are rarely seen in patients with cluster
headache, although women present with these symptoms more often
than men and are more likely to have coexistent migraine and
cluster headache.
Patient behavior differs dramatically with cluster headache
versus migraine. Whereas the migraine patient prefers the refuge
of a bed in a darkened, quiet room, a patient with cluster
headache exhibits agitation, including pacing, verbal outbursts,
and threats to harm themselves or others.
“I have had patients who hit their head against a wall to try to
get rid of the pain,” said Dr. Freitag.
In about 10% of patients, cluster headache evolves from an
episodic to a chronic condition. Transition to chronic cluster
headache is characterized by loss of circadian or circannual
features, and rarely does a remission last longer than 2 weeks.
Patients tend to be in pain continually, are often resistant to
common therapies, and frequently develop tachyphylaxis to
preventive treatments.
“Essentially, the remission periods end, and the headache cycle
continues without interruption,” said Dr. Freitag. “Most
patients have no remissions, but when remissions do occur, they
are very brief.”
After cluster headache makes the transition to a chronic
condition, the pain usually continues for a year or even longer
before showing any signs of resolution. In some patients, a
headache cycle may last a decade or longer.
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