triggered by emotional impact a case report 12 S á ndor PS 2 Irimia P 3 Jager HR 2 Goadsby PJ 2 Kaube H 1 Headache amp Pain Unit Neurology Dept University Hospital Zurich Switzerland ID: 911080
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Onset of Cluster Headache (CH) triggered by emotional impact: a case report.
1,2Sándor PS, 2Irimia P, 3Jager HR, 2Goadsby PJ, 2Kaube H
1Headache & Pain Unit, Neurology Dept., University Hospital Zurich, Switzerland2Headache Group, Institute of Neurology, Queen Square, London, UK3Lysholm Department of Neuroradiology, Queen Square, London, UK
Background: Cluster headache Neuroimaging - activation in the posterior hypothalamus [1] - subtle structural abnormalities (same region) [2] Genetic studies - autosomal dominant inheritance - low penetrance - increase risk 4-18 times for first degree relatives [3] triggers of individual attacks well recognized (Nitroglycerin,[4] alcohol,[5] increased body heat, exertion[6]) no described triggers of bouts
ConclusionExtreme emotional stress can be a trigger of cluster headache.
Case
A 51-year
old male migraine without aura from the age of 13 good response to subcutaneous sumatriptan 6mg after 10 years of marriage, difficult divorce struggle to maintain contact with his 3 children. After having remarried his son had been living with him unexpectedly his son had announced to move back with his mother, the patient's ex-wife. He described this to have been the „worst moment in years“ early evening of the same day: a new type of headache started: - frequency: two attacks per day - pain: was strictly left temporo-parietal - with lacrimation, conjunctival injection and restlessness successful self treatment with subcutaneous sumatriptan Family history: positive for migraine Past medical history: unremarkable Neurological examination: normal Medical examination: unremarkable MRI: normal. Diagnosis: cluster headache Prednisolone and methysergide with good headache control
We propose a causal relationship between the extreme emotional stress and the onset of his cluster headaches.Placebo effects in cluster headache therapy (comparable in magnitude to migraine [17]) are mediated by information and induce neurobiological changes. Emotional stress as a trigger, also mediated by information, might be another example that Descartes’ heritage in research of trying to conceptually separate the brain from the results of its function is outdated.
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Soros P, Frese A, Husstedt IW, et al. Cluster headache after dental extraction: implications for the pathogenesis of cluster headache? Cephalalgia 2001;21:619-22.Romoli M, Cudia G. Cluster headache due to an impacted superior wisdom tooth: case report. Headache 1988;28:135-6.Evers S, Soros P, Brilla R, et al. Cluster headache after orbital exenteration. Cephalalgia 1997;17:680-2.Leor J, Poole WK, Kloner RA. Sudden cardiac death triggered by an earthquake. N Engl J Med 1996;334:413-9.House A, Dennis M, Mogridge L, et al. Life events and difficulties preceding stroke. J Neurol Neurosurg Psychiatry 1990;53:1024-8.Wacogne C, Lacoste JP, Guillibert E, et al. Stress, anxiety, depression and migraine. Cephalalgia 2003;23:451-5.Klimek A. Orgasm-a new trigger factor of cluster headache? Cephalalgia 1990; 10:205-6.Swanson JW, Yanagihara T, Stang PE, et al. Incidence of cluster headaches: a population-based study in Olmsted County, Minnesota. Neurology 1994;44:433-7.Nilsson Remahl AI, Laudon Meyer E, Cordonnier C, et al. Placebo response in cluster headache trials: a review. Cephalalgia 2003;23:504-10.
Mumenthaler M, Regli F.
Der Kopfschmerz. Thieme Verl.
Discussion
New type of headache: cluster headache
previous treatment in specialized headache clinic
for migraine without aura and medication overuse
headache
no suggesion in notes for previous CH
published cases of cluster headache triggered
by - or secondary to lesions localized in
trigeminal territory, such as head injury [8],
dental extraction [9], impacted superior wisdom
tooth[10], or ocular enucleation [11]
Emotional triggers well recognized for
cardiac death[12], stroke[13], migraine[14]
only reported emotional trigger for a first time
cluster headache is orgasm[15]
The emotional stress temporally associated with
the onset of his cluster headaches was extreme
for our patient
Cluster headache: very rare
- prevalence of about 0.2%[3]
- incidence of 1.6 per million/ person-year [16]