Cluster Headache Pain and Symptomatology
A recent survey queried cluster headache patients to compare cluster headache pain intensity to other painful disorders. The results, highlighted in this quick slideshow, may surprise.
Cluster headaches (HA) are considered the third most common primary HA (ie, HA for which there is no identifiable etiology), after tension-type and migraine HA. However, due to the nature of the pain and accompanying symptoms, cluster HA may be misdiagnosed, and the related morbidity underestimated. A recent study published in the journal Headache provides a clearer picture of the nature of cluster HA symptoms. The study is part of the Cluster Headache Questionnaire, a self-administered internet-based cross-sectional survey, and 1604 patients with cluster HA were included in the current study.
The severity of the pain that accompanies cluster HA is revealed by a question regarding how the level of the HA pain on a scale of 0-10 (with 10 being the worst pain) compares with pain from other painful conditions and illnesses respondents may have had, such as labor pain, pancreatitis, nephrolithiasis, and cholelithiasis. Scroll through the slides below for key takeaways from the survey.
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Respondents scored the pain experienced with cluster HA as worse than any other including the pain during labor, pancreatitis, nephrolithiasis, cholelithiasis, and gunshot wounds.
Overall, 72% of respondents rated cluster HA pain as a 10, the maximum pain intensity (mean all respondents, 9.7). In comparison, the next highest mean pain was labor pain (7.2), followed by pancreatitis (7.0), and nephrolithiasis (6.9).
None of the participants who had experienced other painful conditions reported that the pain was worse than cluster HA-related pain.
Due to the limited number of cluster HA patients who also had other conditions causing severe pain, (eg, complex regional pain syndrome, pain secondary to spinal cord injury), authors noted it’s impossible to compare levels of pain experienced in patients who had these and cluster HA.
In addition to pain, many who suffer cluster HA also experience cranial autonomic symptoms. Study authors examined the relationship between those symptoms and the cluster HA pain.
Respondents with maximal pain were statistically significantly more likely to have cranial autonomic features vs those with less pain, including:
• Conjunctival injection or lacrimation
• Eyelid edema
• Forehead/facial sweating
• Fullness in the ear
• Miosis/ptosis
It is worth noting that nasal congestion was the only cranial autonomic symptom not associated with worse pain.
Regarding medications to manage cluster HA pain, no difference was observed in the amount of relief experienced with acute or preventive medications with the exception of calcium channel blockers, which were found to be more effective for participants with less pain.
Greater pain was also associated with:
• More attacks per day, but not the duration of attacks
• Greater levels of hopelessness (as measured by the Hopelessness Depression Symptom Questionnaire), but not depression (as measured by the Beck Depression Inventory)
• Female sex
Another interesting finding was that respondents with maximal pain were more likely female (34%) vs male (24%). The male:female ratio for cluster HA is considered to be approximately 4:1, so it is presumed to be relatively rare in women; in this survey, 31% of participants were women. A recent study published in JAMA Neurology found that while cluster HA are believed to have a genetic component, that tendency appears strongest among women.
Conclusions:
• Cluster HA is extremely painful.
• The association between the level of pain and presence of cranial autonomic symptoms indicates they are not an all-or-none phenomenon, but on a continuum associated with pain level.
• It is unclear whether the underlying etiology of these symptoms is involved in the pain.
Conclusions (cont.):
• The association between pain severity and level of hopelessness raises concerns about the possibility of suicide; warrants further investigation as hopelessness is associated with an increased risk for suicide.
• Why calcium channel blockers (unlike other medications used to treat cluster HA) appear to be less effective for those with more pain is unclear; warrants further investigation.
Conclusions (cont.). The higher levels of pain among women with cluster HA, and the possible stronger genetic component among women, suggests the possibility that there is some difference between the sexes as to etiology of the HA.
