Symptomatic cluster headache in internal carotid artery dissection--consider anhidrosis

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.

Carotid dissection presenting as a prolonged cluster-like headache in a patient with episodic cluster headache

We present a patient with known episodic cluster headache, who presented with cluster-like headache in the course of internal carotid artery dissection (ICAD) and discuss possible pathophysiological links between the two diseases. It is well known that cluster-like headache could be the presenting symptom of ICAD. However, ICAD occurring in a patient with a known episodic cluster headache was only once previously described. In the end of the manuscript, we propose red flags to help clinicians differentiate between primary cluster headache and cluster-like attacks masking underlying ICAD. Finally, we raise the question whether at least some proportion of those patients with cluster headache and Horner syndrome previously classified as a primary headache disorder might have been secondary cases to ICAD.

Segmental cavernous carotid ectasia in a patient with cluster-like headache

INTRODUCTION

Cluster headache (CH) is a primary headache with severe, unilateral periorbital or temporal pain lasting 15-180 min, accompanied with various cranial autonomic features. A diagnosis of cluster-like headache can be made whenever underlying cause of CLH is present.

METHODS AND RESULTS

We report a case where an ectatic cavernous segment of the internal carotid artery triggered CHL, most probably due to compression of the ophthalmic nerve within cavernous sinus. The pathological substrate of a vessel ectasia is degeneration of the tunica intima as a consequence of atherosclerosis and hypertension. On the other hand, cavernous sinus is unique space where parasympathetic, sympathetic and nociceptive fibers are in intimate relationship which is of great importance for understanding of CH pathophysiology.

CONCLUSION

Magnetic resonance imaging and MR angiography are mandatory imaging tools used for precise localization of pathological changes in the cavernous sinus, especially in the group of secondary headaches attributed to vascular disorders.

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.

Carotid dissection mimicking a new attack of cluster headache

Background

Symptomatic cluster headache (CH) secondary to internal carotid artery dissection (ICAD) has been frequently reported, however, as far as we know, the coexistence of episodic CH and acute symptomatic CH secondary to ICAD has not.

Case report

A 39 year-old man, affected by episodic CH since the age of 19, presented an atypical headache associated with his usual autonomic symptoms. After a series of negative tests, MRA eventually revealed dissection of the right distal internal carotid artery.

Discussion and conclusions

The coexistence of episodic CH and acute CH symptomatic of ICAD in our patient suggests that, at least in some cases, CH and ICAD may be different expressions of a common underlying cause: hidden vessel wall damage. When risk factors and the change - though partial - of clinical features suggest symptomatic cases, CH patients have to be strictly monitored over time. Given the lack of a gold standard investigation for dynamic diseases such as dissections, these patients require multimodal diagnostic investigation over time, even in cases where exams are normal at onset.

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.

A patient with internal carotid artery dissection

BACKGROUND AND PURPOSE

The purpose of this case report is to raise physical therapist awareness of Horner syndrome as a "red flag" for immediate medical referral.

CASE DESCRIPTION

A 45-year-old man sought physical therapy for examination and treatment of neck pain and headache symptoms 5 days after experiencing a whiplash-type injury while waterskiing. His complaints were similar to a prior condition diagnosed as occipital neuralgia that had successfully responded to education, cervical and thoracic joint mobilization, and exercise provided by a physical therapist. The initial examination findings also were similar to those of the previous episode. However, signs consistent with Horner syndrome were noted on the second visit. This finding raised immediate concern on the part of the treating clinician and resulted in prompt physician referral, medical diagnosis, and intervention.

OUTCOMES

A magnetic resonance imaging angiogram revealed an internal carotid artery dissection. A successful outcome was achieved over the course of 6 months through medical intervention, which consisted of anticoagulant therapy and modification of activity levels.

DISCUSSION

In this case, the patient's sudden onset of signs of Horner syndrome was indicative of a medical emergency-internal carotid artery dissection.

Cerebrovascular Dissections—A Review Part I: Spontaneous Dissections

Spontaneous cerebrovascular dissections are subintimal or subadventitial cervical carotid and vertebral artery wall injuries and are the cause of as many as 2% of all ischemic strokes. Spontaneous dissections are the leading cause of stroke in patients younger than 45 years of age, accounting for almost one fourth of strokes in this population. A history of some degree of trivial trauma is present in nearly one fourth of cases. Subsequent mortality or neurological morbidity is usually the result of distal ischemia produced by emboli released from the injury site, although local mass effect produced by arterial dilation or aneurysm formation also can occur. The gold standard for diagnosis remains digital subtraction angiography. Computed tomography angiography, magnetic resonance angiography, and ultrasonography are complementary means o evaluation, particularly for injury screening or treatment follow-up. The annual rate of stroke after injury is approximately 1% or less per year. The currently accepted method of therapy remains antithrombotic medication, either in the form of anticoagulation or antiplatelet agents; however, no class I medical evidence exists to guide therapy. Other options for treatment include thrombolysis and endovascular therapy, although the efficacy and indications for these methods remain unclear.

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.

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.

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.

Two cases of symptomatic cluster-like headache suggest the importance of sympathetic/parasympathetic balance

Despite several reports on symptomatic cluster-like headache, there is no clear explanation of how different lesions thought to be causative are related to cluster-like headache. On the basis of two additional cases of symptomatic cluster headache, we discuss the possibility that an acute imbalance of the autonomic nervous system, namely a net overactivity of the parasympathetic system, may be able to trigger these headache attacks in patients who probably have an additional individual predisposition to react with a cluster-like headache. Such an imbalance can be due to an increase in parasympathetic tone (e.g. stimulation of parasympathetic fibres) or to a reduction of the sympathetic tone (e.g. a lesion of the sympathetic fibres).

Cluster headache and head trauma: Is there an association?

This article discusses what is known of and written regarding the possible association of cluster headache and head trauma. There is additional discussion of conditions other than direct head trauma that are also seen in association with cluster headache. These conditions bring into question the concept of primary versus secondary cluster headache and raise the possible need to expand the category of secondary cluster headache. With increasing knowledge of the pathophysiology of cluster headache, the potentially causative role of head trauma in the development of cluster headache may become better defined.

Síndrome de Claude Bernard-Horner associada ao empiema pleural

A síndrome de Claude Bernard-Horner apresenta várias etiologias, ocorre por interrupção do estímulo nervoso em qualquer ponto do trajeto do nervo e pode ser intra ou extratorácica. É relatado um caso dessa síndrome causado por empiema pleural septado, localizado em região paravertebral, no terço superior do hemitórax direito. O paciente foi submetido à toracotomia para drenagem da cavidade pleural. A evolução foi satisfatória, com regressão do quadro infeccioso, expansão pulmonar e remissão da síndrome.

[Long-lasting, refractory headache after bilateral dissection of the internal carotid artery]

Headache is usually the first and the most frequent symptom of cervicocephalic arterial dissection. Besides headache ipsilateral Horner's syndrome, cranial nerve palsies, or pulsatile tinnitus are observed. Serious complications of arterial dissection are ischemic strokes, which mostly occur later in the course of time. We report on a patient with spontaneous bilateral carotid artery dissection, who suffered from atypically prolonged, severe, and refractory headache. High-dose administration of nonsteroidal anti-inflammatory drugs as well as opioids were ineffective. Pain relief was only achieved after a 3-day course of corticosteroids (100 mg methylprednisolone/day).

Peripheral postganglionic sympathicoplegia mimicking cluster headache attacks

After dissection with complete occlusion of the internal carotid artery, a 58-year-old man started to suffer from intense cluster headache-like attacks. Magnetic imaging showed signs of nonsymptomatic cerebral emboli, which could be dated to have occurred in temporal relation to the start of the attacks, all on the right side. This case and two similar ones indicate that peripheral postganglionic sympathicoplegia can cause attacks with similar pain characteristics, accompanying symptoms, duration, and regularity as in cluster headache.

Symptomatic Hemicrania Continua After Internal Carotid Artery Dissection

We report a male patient with a right internal carotid artery (ICA) dissection and a consecutive hemicrania continua (HC) fulfilling the criteria of the International Headache Society. This is the first time that a HC secondary to ICA dissection has been reported.