Cluster headache occurs predominantly in men in the fourth decade. This condition is also known as migrainous neuralgia. Current concepts on pathophysiology suggest disturbances within the hypothalamus, with relevant involvement of autonomic systems and alterations in melatonin function.

Attacks occur in clusters lasting four to 10 weeks. Frequent attacks occur during the day and during sleep. Headaches last 45 minutes approximately. Precipitating factors include alcohol and altitude.

Case report

A 37-year-old married man, employed as a painter, presented to his general practitioner, with a one-year history of sudden onset of left-sided facial pain radiating to his left forehead and left side of neck. 

This pain has become a regular feature of his life over the year. The pain is associated with nasal obstruction, tearing of his left eye and drooping of his left eyelid. He suffers from rhinorrhoea at the same time. The pain is exacerbated by alcohol consumption.

The patient initially had physiotherapy which was of little benefit. He consulted a dentist and subsequently attended a neurologist, who excluded trigeminal neuralgia. An MRI brain scan was normal. 

The neurologist diagnosed him as having migraine. The patient was advised to take amitriptyline 50mg nocte from which he derived benefit. Topiramate, pregabalin and zolmitriptan were of little benefit. Neurological examination was unremarkable.

The patient was eventually referred to the hospital pain team and was diagnosed as having ‘cluster headache’. The patient responded to the use of 100% oxygen for the initial 10-15 minutes of the attack. His dose of amitriptyline was reduced to 10mg nocte to reduce drowsiness. 

He was commenced on naproxen/esomeprazole two tablets/day as an interim measure while awaiting procurement of indomethacin.

Currently the patient is no longer on oxygen. He takes Indomethacin 25mg tds and esomeprazole 40mg od with excellent relief of his symptoms.

The patient is very pleased and he attends the hospital as an outpatient every three months

Conclusion

Cluster headache is a rare disorder affecting mainly males. It presents as severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes untreated. The headache is associated with at least one of the following signs, which have to be present on the same side as the pain: 

• Conjunctival injection
• Lacrimation
• Nasal congestion
• Rhinorrhoea
• Forehead and facial sweating
• Miosis
• Ptosis 
• Eyelid oedema. 

Acute attacks respond to triptans administered intranasally or intramuscularly, 100% oxygen by inhalation and a short course of prednisolone. In this case, the patient after having been subjected to various treatments, eventually responded well to oxygen and indomethacin.

References

1. Goadsby PJ. Recent advances in the diagnosis and management of migraine. BMJ 2006; 332(7532):25-29
2. Connor HE. The aetiology of headache. Pain reviews 1994