Q: Doctor what is cluster headache and can a patient get relief from physical therapy?

A: Cluster headaches stand out as the rarest but most excruciating among the primary headache disorders, which encompass trigeminal autonomic cephalalgias (TACs), migraines, and tension-type headaches. Among the TACs, cluster headaches rank as the most prevalent. These primary headaches stem from the spontaneous activation of nociceptive pathways. Clinically, cluster headaches are characterized by recurrent, short-lasting attacks lasting from 15 to 180 minutes, typically averaging around 45 to 90 minutes. The attacks typically entail severe, unilateral periorbital or temporal pain described as sharp, pulsating, pressure-like, burning, or piercing, often manifesting on the right side of the head. Additionally, the presence of at least one ipsilateral autonomic symptom is necessary for diagnosis, which may include conjunctival injection, lacrimation, nasal congestion or rhinorrhea, forehead and facial sweating, facial flushing, eyelid edema, miosis, ptosis, and a sense of restlessness and agitation.

Cluster headaches manifest in two main forms: episodic and chronic. Episodic cluster headaches are marked by periods of susceptibility to headaches, known as cluster periods, alternating with periods of remission. During a cluster period lasting 1 to 3 months, patients may experience 1 to 8 attacks per day, followed by remission periods lasting months to years. In the episodic classification, headaches can recur in the same pattern after remission, often exhibiting clock-like regularities and showing a propensity for seasonal variations. Conversely, chronic cluster headaches involve cluster periods lasting for one year or more without significant remission or with remission periods lasting less than one month. Chronic headaches typically evolve from episodic headaches over time. Around 80% of all cases are episodic headaches, while approximately 20% are chronic headaches. Clinical signs and symptoms include severe headache localized to one eye and the frontotemporal region, temporal artery bulging and pulsating, unilateral ptosis, eyelid swelling and redness, miosis, conjunctival injection, tearing, nasal congestion, rhinorrhea, and flushing and sweating on the affected side of the face.

Recent studies have highlighted the coexistence of migraine-like symptoms in some individuals diagnosed with cluster headaches, such as auras, photophobia, phonophobia, and nausea and vomiting. Attacks often occur at predictable times each day, often upon waking from an afternoon nap or during nighttime sleep. Physical activity tends to alleviate pain during a cluster headache, prompting patients to prefer standing or sitting erect over lying down. During the cluster period, patients may exhibit restlessness and engage in rocking motions, head-hitting behaviors, or self-injurious actions. Diagnosis of cluster headache hinges on whether symptoms align with clinical criteria and the exclusion of secondary causes. Given the limitations of diagnostic tests in confirming a diagnosis of cluster headaches, obtaining a detailed clinical history is paramount.

Misdiagnosis of cluster headaches is common, leading to delays in appropriate treatment. It may take from 3 to 9 years to arrive at a correct diagnosis. Triggers for cluster headaches include nitroglycerin, hypoxic conditions, alcohol consumption, changes in sleeping patterns, elevated body temperature, volatile or strong odors, and bright or flashing lights. Educating patients about their headache triggers is crucial, and maintaining a headache journal can aid in identifying these triggers. The preferred practice pattern for treating cluster headaches involves addressing impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system acquired in adolescence or adulthood. Biofeedback techniques such as thermal and EMG biofeedback may offer benefits in managing cluster headaches. Physical therapists play a vital role in educating patients about common triggers and precipitating factors to avoid, including alcohol consumption, abrupt changes in sleep patterns due to travel or work shifts, lack of sleep, naps, bursts of anger, prolonged anxiety, altitude hypoxemia during flights, and aggressive exercise may help alleviate symptoms in cluster headache patients. It is important to consider that many patients with cluster headaches may be taking medications that can cause systemic adverse effects, which may directly affect their ability to engage in exercise. Thus, awareness of the patient's medication regimen is crucial for optimizing their treatment plan.