Expert Opinion - rwevansmd.com

1 Expert Opinion 694 Is It migraine or Cluster? Case History Submitted by Randolph W. Evans, MD Expert Opinion by Seymour Solomon, MD Key words: recurrent headaches, cluster, migraine ( Headache 2000;40:694-695) A headache with a cluster pattern but withoutautonomic features is difficult to classify. CLINICAL HISTORY This 27-year-old woman has had similar recur-ring headaches since aged 12. She reports a severe,right retro-orbital and temporal pressure associatedwith nausea and vomiting but no aura, light or noisesensitivity, ptosis, nasal congestion, tearing, or eyeredness.

2 The headaches almost always awaken her about 3 to 4 AM and last 1 to 3 hours. During theheadache, she lies quietly in bed. Over the years, theheadaches typically begin during her menses and re-cur once daily, occasionally twice, for about 3 headaches then go away, but recur about 18months later. Midrin and over-the-counter medica-tions have not helped. Neurological examination isnormal. I gave her sumatriptan nasal spray, 20 mg,which relieved the headache within 15 minutes.

3 Questions. What is the diagnosis? Could this becluster- migraine ? Would preventative treatment beof benefit? Expert COMMENTARY The characteristics of this woman s headacheshave features of migraine (unilaterally, severe inten-sity, associated nausea and vomiting) and some fea-tures of cluster headache (retro-orbital pain locked toone side of relatively short duration occurring in clus-ters). The preference for rest during the attack andaggravation by menstruation supports the diagnosisof migraine , and the nocturnal occurrence during thecluster periods supports the diagnosis of cluster head-ache.

4 The headache characteristics barely fulfill themajor criteria of migraine without aura of the Inter-national Headache Society (IHS), but there are notenough features of cluster headache to meet IHS cri-teria for that diagnosis. 1 Features favoring clusterheadache, such as the retro-orbital site locked to oneside and nocturnal occurrence, are often reported bymigraineurs, and even the cyclic occurrence of mi-graine has been reported. 2 Nevertheless, this case hasenough features of cluster headache to warrant thelabel of migraine -cluster headache syndrome.

5 3 However, when dealing with symptoms that arenot typical of one of the primary headaches, furtherevaluation by an imaging study is warranted. Mag-netic resonance angiography, for example, might re-veal a vascular malformation underlying the consis-tently right-sided of the acute attacks in this case is similarto that for migraine or cluster headache. Sumatriptansubcutaneously or by nasal spray is most appropriatebecause of the sudden onset awakening the patientfrom sleep with nausea and vomiting.

6 4 For prophylaxis,each cluster period should be treated as one would treattypical cluster headache, with a brief course of pred-nisone plus verapamil during the weeks of the clusterperiod. 5 Alternatively, I would favor divalproex overpropranolol because the former may be effective for Address correspondence to Dr. Randolph W. Evans, Suite1370, 1200 Binz, Houston, TX 77004 or Dr. Seymour Solomon,Montefiore Medical Center, 3326 Rochambeau Avenue,Bronx, NY 10467. Headache 695both migraine and cluster headache.

7 6 Similarly, in viewof the short cluster period, methysergide would beappropriate. REFERENCES 1. Headache Classification Committee of the Interna-tional Headache Society. Classification and diagnos-tic criteria for headache disorders, cranial neuralgiasand facial pain. Cephalalgia. 1988;8(suppl 7) Graham JR. Cluster headache. Headache. 1972;11 Solomon S, Karfunkel P, Guglielmo KM. migraine -cluster headache syndrome. Headache. 1985;25 The Sumatriptan Cluster Headache Study of acute cluster headache with sumatrip-tan.

8 N Engl J Med. 1991;325 Solomon S, Lipton RB, Newman LC. Prophylactictherapy of cluster headaches. In: Clinical Neurophar-macology. XIV. New York, NY: Raven Press; 1991 Hering R, Kuritzky A. Sodium valproate in the treat-ment of cluster headache: an open clinical trial. Cephalalgia. 1989;9:195-198.