Investigation
of Demographic and Clinical Features in 131 Iranian
Patients with Cluster Headache
.........................................................................................................................
A.Ghorbani, MD1, A.Chitsaz, MD1,
M.R.Savoj, MD2, M. Etemadifar, MD3.
1. Associated professor, Department of Neurology,
Isfahan Medical University, Iran.
2. Resident of Neurology, Department of Neurology,
Isfahan Medical University, Iran.
3.: Professor, Department of Neurology, Isfahan
Medical University, Iran.
Corresspondence to:
Associated Prof. A. Ghorbani,
Department of Neurology,
Isfahan Medical University,
Iran
Fax: (+98) 311-6684510
Tel: (+98) 311-6685555
E-mail: ghorbani@med.mui.ac.ir
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ABSTRACT
Background:
Cluster headache is defined as 'unilateral,
excruciatingly severe attacks of pain
principally in the ocular, frontal, and
temporal areas recurring in separate bouts
along with daily or almost daily attacks
for weeks to months usually with ipsilateral
lacrimation, conjunctival injection, photophobia
and nasal stuffiness and/or rhinorrhoea'.
Methods: This descriptive study
was performed in the Isfahan Medical University
from June 2006 to June 2007. 131 patients
with definite cluster headache were selected
randomly. Data was taken from past history
and presenting features of patients.
Results: Among with 131 Iranian
patients investigated in our study (referred
with possible diagnosis of cluster headache
from other centers), there were: 120 male,
11 female, 68.7% 20 to 40 years old, 67%
with abrupt onset headache, 90 with pulsatile
pain, 30 with non-pulsatile pain, 2 with
both types, 69.4% with less than 60 minute
duration, 38.8% with similar time occurrence
of headache, more prevalent autonomic
sign, lacrimation, nostril block, vomiting,
prominence of temporal artery, rinorrhoea,
petosis, and profuse sweating , site of
headache: 101 around the orbit, 19 far
from the orbit, 96 with seasonal relationshop,
102 with episodic pattern, 29 with chronic
form, Free period: 60%: 7 to 12 months.
Related foods: dairy products, onions,
vinegar, pickles, fatty foods, fast food,
eggs, toasted foods, pungent foods, cucumbers
and potatoes. Familial and childhood cluster
headache, non alcohol consumption: 22
patients, smoking: 52 patients, history
of head trauma: 15 patients.
Conclusion:
On the basis of this study, maybe there
is a regional and race difference among
different studies. According to treatability
of this type of headache, and morbidity
and costs that are produced by this disease,
more extensive studies on the base of
prevalence, predisposing factors, different
aspects of treatment, and prophylactic
treatments should be taken to provide
patients with more suitable and effective
helps.
Key words:
Cluster headache, headache types, clinical
features.
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The International Association for the Study
of Pain (IASP)1,3 defines cluster
headache as 'unilateral, excruciatingly severe
attacks of pain principally in the ocular, frontal
and temporal areas recurring in separate bouts
with daily or almost daily attacks for weeks
to months usually with ipsilateral lacrimation,
conjunctival injection, photophobia and nasal
stuffiness, and/or rhinorrhoea'1,20.
Prevalence rate of cluster headache was ranged
from 56 per 100,000 (prevalence rate for men
of 115.3 per 100,000) to 326 per 100,000 with
an incidence rate of 2.5 to 9.8 per 100,000
per year in different studies2,22,27,31,32,33,35.
Cluster headache is predominantly a disease
of men. Onset typically begins in the third
decade of life. Periodicity is a cardinal feature
of cluster headache. In most patients, the first
cluster of attacks, the cluster period, persists
on average 6-12 weeks and is followed by a remission
lasting for months or even years. During a cluster,
the patient may experience from one to three
or more attacks in 24 hours, and the attacks
commonly occur at similar times throughout the
24 hours for many days. Onset during the night
or 1-2 hours after falling asleep is common.
In some patients, perhaps as many as 10%, periods
of relief become less common, and the condition
enters the chronic phase in which attacks may
occur daily for months or years1,23,24,28.
The pain is strictly unilateral and almost
always remains on the same side of the head
from cluster to cluster. The pain is generally
felt in the retro-orbital and temporal regions
but may be maximal in the cheek or jaw (lower
syndrome)21. It is usually described
as steady or boring and of terrible intensity
(so-called suicide headache).
The pain intensifies very rapidly, peaking
in 5-10 minutes and usually persisting for 45
minutes to 2 hours. During the pain of cluster
headache, the nostril on the side of the pain
is generally blocked; this blockage in turn
leads to ipsilateral overflow to tears caused
by blockage of the nasolacrimal duct. The conjunctiva
may be injected ipsilaterally, and the superficial
temporal artery may be visibly distended. Profuse
sweating and facial flushing on the side of
the headache have been described but are rare.
Nasal drainage usually signals the end of the
attack1,7,8,9,30,34.
Different treatment strategies (acute, maintenance)
have been mentioned in different references.1,7,11,12,13,14,23,24,26,29.
In our study, we aimed to determine the demographic
and symptomatologic presentation of cluster
headaches in Iranian patients who visited our
health care units.
This descriptive study was performed in the
Isfahan Medical University from June 2006 to
June 2007. 131 patients with definite cluster
headache were selected randomly from patients
referred to Alzahra hospital, Noor hospital
and other neurologist offices (that participated
in this study). With MRI, CT scan, and blood
sample studies other diagnoses were excluded
and those selected had definite cluster headache
criteria on the base of ICD10 criteria. Patients
with non-definite diagnosis or another diagnosis
were not included in our study. We designed
special forms for systematic uptake of needed
information from past history and presenting
features of patients. These forms were completed
by neurologists. The registration form of patients
was attached to the end of this article.
Among 131 Iranian patients investigated in
our study (referred with possible diagnosis
of cluster headache from other centers), 120
patients were male and 11 female. 68.7% had
20 to 40 years (mean age: 35.55 years; range:
18-63). 67% of our patients presented with abrupt
onset headache. Quality of pain was pulsatile
in 90 patients, non-pulsatile in 30 patients
and both these types in 2 patients. In 69.4%
of patients duration of each attack was less
than 60 minutes and in 4.8% was more than 180
minutes. Only in 38.8% of patients, attacks
occurred in similar times (32 patients 1 hour
after falling asleep and 19 patients between
2300 hours to 200 hours).
More prevalent autonomic signs presented with
headache in order of prevalence were: lacrimation
(102 patients), nostril block (90 patients),
vomiting (70 patients), prominence of temporal
artery (52 patients), rhinorrhea (50 patients),
petosis (36 patients), and profuse sweating
(30 patients).
Predisposing factors obtained in our study were:
stress (106 patients), smoking (52 patients),
special foods (40 patients), cold (35 patients),
flashing lights (32 patients), alcohol (22 patients),
heat (16 patients), history of head trauma (15
patients).
Among special foods to which 40 patients described
a relation to their headaches there were: dairy
products, onions, vinegar, pickles, fatty foods,
fast food, eggs, toasted foods, pungent foods,
cucumbers, and potatoes.
Among 22 patients with a history of alcohol
consumption, 17 patients reported beginning
or deterioration of headache with alcohol use
and among 52 smokers, 17 patients did. All of
15 patients with history of head trauma had
this event 10 years after.
Site of headache in 101 patients was around
the orbit (70 in the right side and 31 in the
left side) and in 19 patients far from the orbit.
More common site of pain radiation was the ipsilateral
forehead and cheek.
In 96 patients, environment had no effect on
the pain relief. In 61 patients pain commencement
was related to season (23: winter, 20: summer,
12: autumn, 6: spring). 102 patients had episodic
pattern and 29 patients had chronic form. In
almost all patients periodicity of attacks were
one or two attacks daily. In 102 patients with
episodic patterns, 58 patients described duration
of each episode 4 to 8 weeks and 26 patients
about 4 weeks.
Free period between each episode was from 1
month to 3 years that were 7 to 12 months in
60% of these patients.
In our study, we did not find familial or childhood
cluster headache among our patients.
In our study, the follow up for treatment was
not performed. Patients with non-cluster headache
were not investigated and classified in our
study.
There was no appropriate data from Iranian
patients about cluster headache accessible in
different investigations and therefore we could
not compare our results with other Iranian data.
We compared our results with data from developed
countries.
In our investigation the male to female ratio
was 11:1 that is significantly higher than other
studies (6:1) 15,25,32. Quality of pain in other
studies was often non-pulsatile but in our study
more than one-half of patients had pulsatile
headache quality 16,20,23,24. Often pain was
unilateral and only 6.8% of patients had radiation
of pain to other side (15% in other studies)17,20,23,24.
62% of patients had pain without predictable
diurnal pattern but in other studies headache
was beginning among 21 to 10 o'clock1,18,23,24.
Only 38.8% of patients had special diurnal pattern
for headache and these findings are against
the theory of biologic clock effect on periodicity
of cluster headache20,37,38. According
to data from history of head trauma that at
least was presented 10 years before beginning
of cluster headache, it seems that there is
no relation between head trauma and cluster
headache. This finding is according to the Kudrow
(1980)19 study and against the Manzoni
(1983)17 study17,18,36.
In our study we did not find any patients with
document of cluster headache occurrence in their
family that is accordant with other studies3,4.
Childhood cluster headache was not found in
our study (in other studies the presentation
of childhood cluster headache was rare)5,6,10.
In other aspects of our study, the results
are similar to other studies that were done
in other countries1,15,16,17,18,19,27,31.
On the basis of this study, we found that maybe
there is a regional and race difference among
different studies. According to treatability
of this type of headache, mortality, and costs
that are produced by this disease, more extensive
studies on the base of prevalence, predisposing
factors, different aspects of treatment and
prophylactic treatments should be taken to provide
patients with more suitable and effective help.
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