diagnosis

Patients with cluster headaches can usually describe the onset of their attacks in great detail. However, recording the duration of a cluster headache attack can sometimes be problematic. When two, three, or four cluster headache attacks occur, patients are often unsure whether it is a single attack lasting eight hours with breaks, or whether it is a series of attacks. In such cases, keeping a headache diary can provide more precise information. As long as patients have not sought medical treatment, they will generally have taken a variety of painkillers. Since a cluster headache attack usually subsides after an hour, patients often believe that the relief is due to the medication. It is only because of the long duration of cluster periods and the accompanying neurological symptoms that patients then seek help. To make a diagnosis, the characteristics of the headache attack must be precisely ascertained. These include, first and foremost, the duration, the unilateral nature of the headache, the severity of the attack, the typical accompanying symptoms, the location of the headache in the eye area, and also the patient's behavior during the attack.

Since patients often do not perceive the accompanying neurological disorders themselves, it is recommended to ask the patient to look in the mirror during the attack.

A particularly simple yet precise way to document headache characteristics and show them to the treating physician is to have a family member film the headache attack with a video camera or photograph it with a camera. It is especially important to record any changes in the affected eye.

A thorough neurological and general examination is required for diagnosis. Additional diagnostic tests, such as computed tomography (CT) or magnetic resonance imaging (MRI) scans, currently do not provide specific diagnostic information. However, there are situations where doubt exists as to whether the headache disorder is primary. Such doubt arises particularly when the following conditions are present:

  • First occurrence of cluster headache in a very young patient (under 20 years of age) or in patients over 60 years of age.
  • A thorough neurological examination with additional imaging procedures is particularly necessary if the headache has a gradually increasing course or if additional uncharacteristic accompanying disorders occur, especially concentration problems, memory problems, nausea, vomiting, disturbances of consciousness, epileptic seizures, etc.

Given the aforementioned criteria, the primary imaging procedures ordered are magnetic resonance imaging (MRI) of the brain and computed tomography (CT) of the bony skull base. Particular attention should be paid to any possible pituitary tumor or mass in the skull base region (e.g., metastasis). Nasal and paranasal sinus lesions must also be assessed.

Course

A characteristic course of cluster headaches cannot be specified in individual cases. Long-term epidemiological studies are lacking. Active cluster headache production after the age of 75 is almost never observed. Transitions from episodic to chronic cluster headache, and vice versa, can be observed. The influence of prophylactic medication on the spontaneous course remains unknown.

80% of patients with primary episodic cluster headache still suffer from episodic cluster headache after 10 years, while 12% develop chronic cluster headache after a primary episodic course.

In over half of those affected by primary chronic cluster headache, this chronic form persists even after 10 years without any prolonged periods of remission. Only in approximately 10% can a longer-lasting remission phase of more than three years be expected.