Cluster headache-like headaches: a symptomatic feature? A report of three patients with intracranial pathologic findings

Cluster headache due to structural lesions: A systematic review of published cases

BACKGROUND

Cluster headache (CH) is a severe incapacitating headache disorder. By definition, its diagnosis must exclude possible underlying structural conditions.

AIM

To review available information on CLH caused by structural lesions and to provide better guides in the distinguishing process and to ensure that there is not a potentially treatable structural lesion.

METHODS

We conducted a systematic review of 77 published cases of symptomatic CH and cluster-like headache (CLH) in PubMed and Google Scholar databases.

RESULTS

Structural pathologies associated with CH were vascular (37.7%), tumoral (32.5%) and inflammatory (27.2%). Brain mass-like lesions (tumoural and inflammatory) were the most common diseases (28.6%), among which 77.3% lesions were at the suprasellar (pituitary) region. Cases of secondary CH related to sinusitis rose dramatically, occupying 19.5%. The third most common disease was internal carotid artery dissection, accounting for 14.3%. Atypical clinical features raise an early suspicion of a secondary cause: Late age at onset and eye and retroorbital pains were common conditions requiring careful evaluation and were present in at least one-third of cases. Abnormal neurological examination was the most significant red flag for impaired cranial nerves. CLH patients may be responsive to typical CH treatments; therefore, the treatment response is not specific. CLH can be triggered by contralateral structural pathologies. CLH associated with sinusitis and cerebral venous thrombosis required more attention.

CONCLUSION

Since secondary headache could perfectly mimick primary CH, neuroimaging should be conducted in patients in whom primary and secondary headaches are suspected. Cerebral magnetic resonance imaging scans is the diagnostic management of choice, and further examinations include vessel imaging with contrast agents and dedicated scans focusing on specific cerebral areas (sinuses, ocular and sellar regions). Neuroimaging is as necessary at follow-up visits as at the first observation.

Efficacy of cabergoline and triptans for cluster-like headache caused by prolactin-secreting pituitary adenoma: A literature review and case report

OBJECTIVE

Cluster-like headache (CLH) associated with pituitary adenoma (PA) is rare. Although numerous cases have been reported, no summary of the literature has been published. Furthermore, the mechanism and efficacy of medication in CLH associated with PA remains unknown.

METHODS

We reviewed 14 cases of CLHs associated with PA published in the English and Japanese literature. We have also included and presented our experience with such a case.

RESULTS

The median age of patients with CLHs associated with PA was 46 years (range, 17-58 years). The ratio of men to women was 14:1. Headache duration ranged from 15-480 min, with left fronto-orbital pain being common. The most common autonomic nervous symptoms were eye-related in 13 patients (86.6 %), followed by nasal symptoms in 12 (80.0 %). Thirteen patients (86.6 %) had functional adenomas; the remaining two were nonfunctional. Twelve of the functional adenomas were lactotroph adenomas (80.0 %), and one was a somatotroph adenoma (6.6 %). CLHs significantly improved after cabergoline administration in 7/9 patients with a lactotroph adenoma (77.7 % response rate). In 5/11 patients with either a functional or nonfunctional PA who received a triptan, CLHs improved (45.4 % response rate).

CONCLUSION

Based on the efficacies of cabergoline and triptans, two different mechanisms may coexist in the pathogenesis of CLHs associated with PA: endocrinological and physical effects of the tumor itself. Cabergoline is the first-line treatment for headaches caused by lactotroph adenomas. Triptans can be effective as an acute drug for headaches associated with nonfunctional PAs and persistent headaches that remain after cabergoline administration.

Chronic paroxysmal headache secondary to an orbital metastatic leiomyosarcoma: A case report

Background Intraorbital lesions associated with symptomatic trigeminal autonomic cephalalgias (TACs) are rarely reported. We present a case of orbital metastatic leiomyosarcoma, presenting with chronic paroxysmal hemicrania-like headache. Case report A 43-year-old man presented with a severe paroxysmal headache in his left periocular and frontal area for a year. The attacks occurred 10-12 times per day, lasting 10-15 minutes with ipsilateral lacrimation and conjunctival injection. Neurological examination and brain MRI without contrast were unremarkable. Different medications were tried, without beneficial effects. A follow-up contrast-enhanced brain MRI performed one year after the baseline MRI revealed an enhancing mass in the left superior oblique muscle. Orbital metastatic leiomyosarcoma arising from the thigh was revealed. He received gamma knife surgery, which completely resolved the headache. Discussion Intraorbital lesion should be considered a possibility in patients with headache mimicking TACs. Baseline contrast-enhanced MRI is essential, and repeated MRI scans might be needed if clinically indicated.

Chronic Paroxysmal Hemicrania in a Patient with a Macroprolactinoma

We report a patient with headaches meeting the criteria of chronic paroxysmal hemicrania, as defined by the International Headache Society classification. Headaches were fully responsive to indomethacin during the first 3 months of treatment but recurred when daily doses were lowered. Investigations revealed a macroprolactinoma. Headaches stopped after cabergoline treatment. This report further suggests that patients with paroxysmal hemicrania should be investigated for pituitary abnormalities.

Structural imaging in cluster headache

Cluster headache is a rare primary headache disorder and the most common trigeminal-autonomic cephalalgia. Even though it has been extensively studied, its pathophysiology remains nebulous. Over the last two decades, cerebral imaging has increasingly been used to aid the investigation of pain and headache disorders. Pioneering work using magnetic resonance-based, voxel-based morphometry depicted an isolated increase of grey matter in the posterior hypothalamus and thereby reconfirmed the most commonly accepted pathophysiological concept. More recent works demonstrate structural changes across multiple structures related to pain processing, sensory integration, and emotional evaluation. These changes do not seem to be static, but rather appear to be dynamic in nature as they change over the course of the disease. This was interpreted as a reflection of the plasticity of the human brain and should guide future thoughts towards a more complex pathophysiological model involving a maladaptive pain modulatory network.

Symptomatic cluster headache: a review of 63 cases

Cluster headache is a primary headache by definition not caused by any known underlying structural pathology. Symptomatic cases have been described, for example tumours, dissections and infections, but a causal relationship between the underlying lesion and the headache is difficult to determine in many cases. The proper diagnostic evaluation of cluster headache is an issue unresolved. The literature has been reviewed for symptomatic cluster headache or cluster headache-like cases in which causality was likely. The review also attempted to identify clinical predictors of underlying lesions in order to formulate guidelines for neuroimaging. Sixty-three cluster headache or "cluster headache-like"/"cluster-like headache" cases in the literature were identified which were associated with an underlying lesion. A majority of the cases had a non-typical presentation that is atypical symptomatology and abnormal examination (including Horner’s syndrome). A striking finding in this appraisal was that a significant proportion of CH cases were secondary to diseases of the pituitary gland or pituitary region. Another notable finding was that a proportion of cluster headache cases were associated with arterial dissection. Even typical cluster headaches can be caused by structural lesions and the response to typical cluster headache treatments does not exclude a secondary form. It is difficult to draw definitive conclusions from this retrospective review of case reports especially considering the size of the material. However, based on this review, I suggest that neuroimaging, preferably contrast-enhanced magnetic resonance imaging/magnetic resonance angiography should be undertaken in patients with atypical symptomatology, late onset, abnormal examination (including Horner’s syndrome), or those resistant to the appropriate medical treatment. The decision to perform magnetic resonance imaging in cases of typical cluster headache remains a matter of medical art.

Cluster headache as a first manifestation of multiple sclerosis: case report and literature review

Cluster headache (CH) is estimated to be the most common primary trigeminal autonomic headache, although it is a rare disabling medical condition. Dominant symptoms of CH include severe unilateral orbital, supraorbital, and/or temporal pain, lasting from 15 to 180 minutes if untreated, associated with at least one of various autonomic symptoms during the headache, such as conjunctival injection, lacrimation, nasal congestion and rhinorrhea, facial sweating, miosis, ptosis, and eyelid edema. Headache is not frequently a symptom of multiple sclerosis (MS). The most commonly reported primary headaches are migraine without aura and a tension-type headache. Several described cases involved complicated migraine, ophthalmoplegic migraine-like headache, and finally cluster-like headache. We present a case of a 45-year-old male patient who had typical CH attacks as the initial and only clinical manifestation of MS, which was diagnosed after cerebrospinal fluid (CSF) isoelectric focusing and brain magnetic resonance imaging (MRI) investigation. He presented as a typical cluster-like headache patient since in the background of the CH symptoms and signs, were MS demyelinating lesions. In a patient with CH symptoms one should always think about the possibility of cluster-like-headache, which presents the CH patient with different underlying diseases, so we proposed a protocol to evaluate such patients and exclude diseases that could be in the background of CH symptoms.

Prolactinoma-associated headache and dopamine agonist treatment

AIM

The aim of this article is to investigate the phenotype and etiology of prolactinoma-associated headache as well as present and discuss the plausible pain-relieving effect of dopamine agonist treatment.

METHODS

In this case-based audit we included 11 patients with prolactinomas and one patient with idiopathic hyperprolactinemia presenting with headache that subsequently improved or resolved after dopamine agonist treatment.

RESULTS

A significant ipsilateral location of tumor mass and reported headache symptoms was observed (p = 0.018). After dopamine agonist treatment seven out of 12 patients became pain free within 2.5 months; after one year of treatment 11 out of 12 reported headache improvement or resolution. Average tumor volume reduction after treatment was 47 ± 22% during 9.5 ± 8.4 months of follow-up. There was no significant association between headache relief and tumor shrinkage (p = 0.43) or normalization of serum prolactin (p = 1.00), respectively.

CONCLUSIONS

1) The significant association between lateralization of tumor and headache suggests a mechanical origin of the headache, 2) headache responded to dopamine agonist treatment in most patients, and 3) our observations encourage future prospective controlled trials to investigate the role of hyperprolactinemia in the pathogenesis of headache as well as the therapeutic effects of dopamine agonists.

Cluster headache - a symptom of different problems or a primary form? A case report

Headache with severe, strictly one-sided unilateral attacks of pain in orbital, supraorbital, temporal localisation lasting 15-180 minutes occurring from once every two days to 8 times daily, typically with one or more autonomic symptoms, is recognized as cluster headache (CH). Headache with normal neurological examination and abnormal neuroimaging studies, mimicking cluster headache, is reported by several authors. We present an elderly woman with a cluster-like headache probably associated with other comorbidities. We differentiate between primary, but 'atypical' CH and symptomatic cluster headache due to frontal sinusitis, pontine venous angioma or vascular compression of the trigeminal nerve root. This headache is not so rare in the general population and its secondary causes must be ruled out before the diagnosis of a primary headache as cluster headache is made.

Cluster-like headache. A comprehensive reappraisal

Among the primary headaches, cluster headache (CH) presents very particular features allowing a relatively easy diagnosis based on criteria listed in Chapter 3 of the International Classification of Headache Disorders (ICHD-II). However, as in all primary headaches, possible underlying causal conditions must be excluded to rule out a secondary cluster-like headache (CLH). The observation of some cases with clinical features mimicking primary CH, but of secondary origin, led us to perform an extended review of CLH reports in the literature. We identified 156 CLH cases published from 1975 to 2008. The more frequent pathologies in association with CLH were the vascular ones (38.5%, n = 57), followed by tumours (25.7%, n = 38) and inflammatory infectious diseases (13.5%, n = 20). Eighty were excluded from further analysis, because of inadequate information. The remaining 76 were divided into two groups: those that satisfied the ICHD-II diagnostic criteria for CH, 'fulfilling' group (F), n = 38; and those with a symptomatology in disagreement with one or more ICHD-II criteria, 'not fulfilling' group (NF), n = 38. Among the aims of this study was the possible identification of clinical features leading to the suspicion of a symptomatic origin. In the differential diagnosis with CH, red flags resulted both for F and NF, older age at onset; for NF, abnormal neurological/general examination (73.6%), duration (34.2%), frequency (15.8%) and localization (10.5%) of the attacks. We stress the fact that, on first observation, 50% of CLH presented as F cases, perfectly mimicking CH. Therefore, the importance of accurate, clinical evaluation and of neuroimaging cannot be overestimated.

Chronic cluster-like headache secondary to prolactinoma: uncommon cephalalgia in association with brain tumors

Headache is a common and disabling aspect of pituitary disease. Chronic and episodic migraine are the most common clinical syndromes of headaches related to pituitary tumors, although other types of headache, such as trigeminal autonomic cephalalgias (TACs), can also be present. TACs include short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing; paroxysmal hemicrania; and cluster headache. We report on a patient with a chronic cluster-like headache associated with a macroprolactinoma. Although cabergoline, pregabalin, and corticosteroids were not effective as preventive treatments, high-dose verapamil showed good efficacy. Morphine and octreotide were efficacious as abortive treatments for attacks, but pain was only partially responsive to oxygen and refractory to subcutaneous sumatriptan.

Cluster headache associated with moyamoya

A 34-year-old man with right-sided cluster headache presented with a stroke from right-sided moyamoya. Following surgery on the right, both moyamoya and cluster headache remitted, but eighteen months later a cluster attack and symptoms of cerebral ischemia from moyamoya recurred on the left. Again, following surgery on the left, both moyamoya symptoms and cluster attacks disappeared. Cluster headache secondary to moyamoya has not previously been described.

Symptomatic cluster-like headache triggered by forehead lipoma: a case report and review of the literature

We describe the case of a patient with symptomatic strictly unilateral paroxysmal headache mimicking cluster headache related to an ipsilateral forehead lipoma. Interestingly, immediately after the surgical excision of the lipoma pain attacks disappeared with no recurrence during a follow-up period of 18 months. Like other descriptions of cluster-like headaches secondary to extracranial lesions, this case report focuses on the hypothetical role of a peripheral trigger factor for trigeminal autonomic cephalgias (TACs). To our knowledge, this is the first well-described cluster-like headache case secondary to an extracerebral lipoma. This case offered the opportunity to discuss the possible pathophysiological mechanisms underlying probable TACs and the relationship with peripheral extracerebral activation of the trigeminal-autonomic reflex.

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome treated successfully with transsphenoidal resection of a growth hormone-secreting pituitary adenoma

Short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome was first described in 1978 as one of the trigeminal autonomic cephalgias. In this paper the authors present a patient with a growth hormone–secreting pituitary adenoma who experienced resolution of SUNCT syndrome after transsphenoidal tumor resection.

Chronic headache and pituitary tumors

Pituitary tumors come to clinical attention due to endocrine dysfunction, distortion of local structures surrounding the pituitary fossa, or as an incidental finding during neuroimaging for headache. Explanations for pituitary tumor-associated headache include stretching of the dura mater and invasion of pain-producing structures within the cavernous sinus. However, small functional pituitary lesions may present with severe headache without cavernous sinus invasion or suprasellar extension. Prolactinomas and growth hormone-secreting tumors have a high prevalence of rare headache phenotypes with or without autonomic features, suggesting that biochemical abnormalities within the hypothalamo-pituitary axis may play a role in headache. Somatostatin analogues may be highly effective at aborting headache associated with functionally active pituitary lesions, particularly in the case of acromegaly. A proposed mechanism for this is inhibition of nociceptive peptides. This article summarizes the clinical features, pathophysiology, and potential treatment approaches to pituitary tumor-associated headache.

Cluster headache and internal carotid artery dissection: two cases and review of the literature

We describe 2 patients with cluster headache attacks associated with a dissection of the ipsilateral internal carotid artery at the extra-intracranial passage. These cases highlight the need for extensive neuroradiological investigation in cluster headache patients when atypical features are present. We also performed a PubMed search to review the current literature data about this association.

Trigeminal autonomic cephalalgias. Part 1: cluster headache

Cluster headache is characterized by severe, strictly unilateral pain attacks lasting 15 to 180 minutes localized to orbital, temporal, and midface areas accompanied by ipsilateral autonomic features. It represents 1 of 3 primary headaches classified as trigeminal autonomic cephalalgias. While its prevalence is small, it is not uncommon for cluster headache patients to present at dental offices seeking relief for their pain. It is important for oral health care providers to recognize cluster headache and render an accurate diagnosis. This will avoid the pitfall of implementing unnecessary and inappropriate traditional dental treatments in hopes of alleviating this neurovascular pain. The following article is part 1 of a review on trigeminal autonomic cephalalgias and focuses on cluster headache. Aspects of cluster headache including its prevalence and incidence, genetics, pathophysiology, clinical presentation, classification and variants, diagnosis, medical management, and dental considerations are discussed.

Neuromodulatory approaches to the treatment of trigeminal autonomic cephalalgias

The trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised by intense pain and associated activation of cranial parasympathetic autonomic outflow pathways out of proportion to the pain. The TACs include cluster headache, paroxysmal hemicrania and SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing). The pathophysiology of these syndromes involves activation of the trigeminal-autonomic reflex, whose afferent limb projects into the trigeminocervical complex in the caudal brainstem and upper cervical spinal cord. Functional brain imaging has shown activations in the posterior hypothalamic grey matter in TACs. This paper reviews the anatomy and physiology of these conditions and the brain imaging findings. Current treatments are summarised and the role of neuromodulation procedures, such as occipital nerve stimulation and deep brain stimulation in the posterior hypothalamus are reviewed. Neuromodulatory procedures are a promising avenue for these highly disabled patients with treatment refractory TACs.

Headache related to brain tumors

Headache is one of the most common somatic complaints of patients seeking medical care. Most headaches are not of serious cause and can be diagnosed easily with a good history and physical examination. The challenges to the physician are to determine when underlying intracranial pathology may be causing the symptoms and signs, and to identify the few patients in whom a tumor is the cause of the headache. The subject of headache in patients with brain tumors has been reviewed in neurologic textbooks and in several investigations before, as well as after, modern imaging diagnostic techniques became available. Headache can also manifest as an acute or chronic complication of radiation treatment and/or chemotherapy in patients with intracranial neoplasm, but there are few data in the literature specifically addressing this subject. This article provides an overview of headache in patients with primary and secondary brain tumor, including headache characteristics, the putative mechanism for these headaches, the role of diagnostic testing, and the general principles of management.

A case of postprandial cluster-like headache with prolactinoma: dramatic response to cabergoline

A 17-year-old boy without a significant past medical history presented with recurrent cluster-like headaches induced by meals for 3 years. Magnetic resonance images showed a pituitary tumor. Just after starting treatment with cabergoline, the headaches resolved completely and the patient has been absolutely free from such headache attacks for 2 years.

The clinical characteristics of headache in patients with pituitary tumours

The clinical characteristics of 84 patients with pituitary tumour who had troublesome headache were investigated. The patients presented with chronic (46%) and episodic (30%) migraine, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT; 5%), cluster headache (4%), hemicrania continua (1%) and primary stabbing headache (27%). It was not possible to classify the headache according to International Headache Society diagnostic criteria in six cases (7%). Cavernous sinus invasion was present in the minority of presentations (21%), but was present in two of three patients with cluster headache. SUNCT-like headache was only seen in patients with acromegaly and prolactinoma. Hypophysectomy improved headache in 49% and exacerbated headache in 15% of cases. Somatostatin analogues improved acromegaly-associated headache in 64% of cases, although rebound headache was described in three patients. Dopamine agonists improved headache in 25% and exacerbated headache in 21% of cases. In certain cases, severe exacerbations in headache were observed with dopamine agonists. Headache appears to be a significant problem in pituitary disease and is associated with a range of headache phenotypes. The presenting phenotype is likely to be governed by a combination of factors, including tumour activity, relationship to the cavernous sinus and patient predisposition to headache. A proposed modification of the current classification of pituitary-associated headache is given.

Resolution of cluster headache after closure of an anterior communicating artery aneurysm: the role of pericarotid sympathetic fibres

We report the case of a patient suffering from migraine without aura since childhood who, at the age of 58 years, developed cluster headache (CH) attacks. This second type of headache was related to an aneurysm of the anterior communicating artery (ACoA) whose bursting caused subarachnoid haemorrhage. The aneurysm's clipping made the cluster headache subside and there was no recurrence for almost four years. However, nine months after haemorrhage, the patient experienced new migraine without aura attacks. As a pathogenetic interpretation of this secondary cluster headache, we discuss the possible role of pericarotid sympathetic nerves in cluster headache attacks. We suggest that the surgical dissection of the pericarotid sympathetic fibres could prevent the onset of the cluster headache attacks by cutting part of the circuit underlying it.

The association between calcitonin gene-related peptide (CGRP), substance P and headache in pituitary tumours

OBJECTIVES

To determine if the differential expression of calcitonin gene-related peptide (CGRP) or substance P (SP) in a range of pituitary tumours was related to the presence or absence of headache.

METHODS

Using recognised immunohistochemical techniques we examined twenty-six consecutive pituitary adenoma specimens for the presence of CGRP and SP. We included one normal post mortem pituitary specimen for comparison. A separate observer divided the patients into two groups: headache and non-headache. The association between the presence of CGRP, SP and headache was observed.

RESULTS

We observed CGRP in seven specimens (27%) and SP in six tumour specimens (23%), with cytoplasmic staining being the predominant morphological picture. CGRP and SP were co-expressed in the same tumour specimen in five cases. There was no significant association between the presence of CGRP and headache (chi(2) 0.86; P = 0.35). We did not observe CGRP or SP in the control specimen. There was no correlation between tumour subtype and the presence of CGRP or SP.

CONCLUSIONS

The mechanism of pituitary tumour-associated headache remains undetermined. The significance of the presence of CGRP and SP in pituitary tumours is unknown but does not appear to be related to headache or endocrine activity of the tumour.

Management of trigeminal autonomic cephalgias and hemicrania continua

The trigeminal autonomic cephalgias (TACs) are a group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features. This group of headache disorders includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome). Although hemicrania continua has previously been classified amongst the TACs, its nosological status remains unclear. Despite their similarities, these disorders differ in their clinical manifestations and response to therapy, thus underpinning the importance of recognising them. We have outlined the clinical manifestations, differential diagnoses, diagnostic workup and the treatment options for each of these syndromes.

Craniometric measures in cluster headache patients

Blockade of venous drainage in the cavernous sinus, which may play a pivotal role in the pathophysiology of cluster headache (CH), could be triggered by local inflammation. It could also be favored by a constitutional narrowness of the cavernous sinus region. Before exploring the latter with magnetic resonance imaging (MRI), we determined whether external morphometric skull measures are different among CH patients (n = 25), healthy volunteers (n = 21), and migraine patients (n = 20). All subjects were males of comparable age distribution. Six measures were taken: inion-nasion perimeter, inion-nasion distance over the vertex; distance between the upper ends of tragus; diameter at the level of the temporal fossa; diameter at mid inion-nasion perimeter at ear level; and inion-nasion diameter. CH patients had significantly smaller values than healthy subjects and/or migraine patients in all but one measure (ANOVA and Duncan's post-hoc analysis). This may suggest that they have a narrower anterior/middle cranial fossa, and possibly a narrower cavernous sinus loggia, which needs to be confirmed by a quantitative MRI study.

Genetic epidemiology of migraine and cluster headache

Migraine. The present genetic epidemiological survey of migraine was based on semi-structured interviews by a physician. The operational diagnostic criteria of the International Headache Society were used. Three thousand males and 1,000 females aged 40 were drawn from the Danish National Central Person Registry. They received a questionnaire by post regarding migraine and the response rate was 87%. People with self-reported migraine and a random sample reporting no migraine were invited to a headache interview and physical and neurological examination. Those not reacting to the invitation were interviewed by telephone. The participation of the interview was 87%. Kappa was 0.77 validating self-reported migraine against a clinical interview by a physician. Non-responders did not differ from responders regarding migraine. The lifetime prevalence of MO and MA was 9.3% and 6.3% in males and 20.1% and 9.6% in females. People with MA were included as probands in the family study. An equivalent number of probands with MO and probands who had never had migraine were random samples of the people with MO) and those who had never had migraine, respectively. First-degree relatives and spouses were interviewed blindly by a physician. The 378 probands had 1,109 first-degree relatives and 229 spouses. Compared with the general population, the first-degree relatives of probands with MO had a 1.9-fold increased risk of MO and a 1.4-fold increased risk of MA, after standardization for sex and age. The first-degree relatives of probands with MA had a 3.8-fold increased risk of MA and no increased risk of MO. The first-degree relatives of probands who had never had migraine had no increased risk of either MO or MA. Spouses to pro-bands with MC) had a 1.5-fold increased risk of MO, while spouses to probands with MA had no increased risk of MA. The familial patterns indicate that MO and MA are distinct entities. The familial occurrence suggests that MO is caused by a combination of genetic and environmental factors, while MA is determined mainly or exclusively by genetic factors. The complex segregation analysis supports the importance of genetic factors and suggests multifactorial inheritance without generational difference in both MO and MA, but genetic heterogeneity cannot be excluded.

Cluster headache syndrome associated with middle cerebral artery arteriovenous malformation

Cluster headache (CH) is an idiopathic cephalalgic syndrome, although several pathological processes have been described in association with this syndrome. We report two cases of cluster headache in hospitalized patients with middle cerebral artery dependent arteriovenous malformation (AVM). After surgical removal of the AVM the headache completely resolved, suggesting that complementary studies and treatment of the underlying aetiology may be indicated for secondary forms of cluster headache.

Resolution of chronic cluster headache after resection of a tentorial meningioma: case report

Cluster headache is almost always idiopathic, but, in rare cases, associated intracranial lesions have been found. We describe a patient who had chronic cluster headache for more than 20 years. The headache immediately resolved upon resection of a tentorial meningioma. Prior reports of cluster headache as a manifestation of structural disease are briefly reviewed. In the patient described, the pain was referred from the right tentorium cerebelli to the right side of the face, in accordance with reported studies on the subjective localization of pain referred from posterior fossa structures. The accompanying abnormalities of autonomic function may have been mediated by central autonomic reflexes that are also involved in the pathogenesis of idiopathic cluster headache.

Symptomatic chronic paroxysmal hemicrania

A patient with chronic paroxysmal hemicrania (CPH) associated with a gangliocytoma growing from within the sella turcica is reported. This tumor displaced the floor of the third ventricle and surrounded the internal carotid artery on the same side as the headache. Partial removal of the tumor followed by radiation resulted in amelioration of headache. The anatomical location of the tumor and its possible relationship to the pathogenesis of CPH is discussed.

Short-lasting unilateral neuralgiform headache attacks with tearing and conjunctival injection: the first "symptomatic" case?

A 36-year-old man was suffering from brief, unilateral and short-lasting pain attacks always associated with marked homolateral tearing and conjunctival injection, both presenting in a cluster fashion. An arteriovenous malformation was subsequently discovered in the homolateral cerebellopontine angle. The clinical picture shares similarities with both cluster headache and trigeminal neuralgia, although it can not be accurately placed with either of these forms. Patients with similar symptoms have previously been described in detail, and on the basis of these few descriptions a new syndrome "short-lasting" unilateral neuralgiform headache attacks with conjunctival injection, tearing, sweating, and rhinorrhoea has been postulated. Assuming the validity of this syndrome as an entity, this case is in all probability its first "symptomatic" example. Careful evaluation of the varieties of cluster headache and trigeminal neuralgia, and the reporting of similar new cases as they arise are necessary to establish the nosologic boundaries of this syndrome.