By Dr. Tarvez Tucker
If you were to hear the phrase “Not tonight, dear, I have a headache,” you might assume the speaker was a woman. While the majority of individuals with recurrent headaches such as migraine and tension-type headache are women, there is one unusual headache syndrome that occurs primarily in men: cluster headache.
Cluster headache causes one of the most severe and agonizing types of pain that humans endure. Although migraine headaches can occur on one side of the head, it switches sides in most patients. Conversely, cluster headache typically affects just once side of the head. Its signature symptom is a "stabbing" pain, usually around or behind the eye and at the temple. This is often accompanied by one-sided nasal stuffiness, forehead sweating or eyelid drooping on the same side as the attack.
The headaches come on rapidly with very little warning and may last anywhere from a few minutes to several hours. The name comes from the headaches' tendency to strike again and again, in “clusters,” once to several times a day for weeks at a time. Then, in most cases, the headache completely disappears for months or even years, only to reappear without warning to begin the terrible cycle all over again.
Although the cause of cluster headache is not known, many men recognize certain triggers. Alcohol is one. Drinking even one sip of beer can bring on the knife-like pain at the temple. One of my patients was so sensitive to alcohol as a trigger that he would get a cluster headache just watching the beer commercials on TV during Sunday night football.
Another intriguing aspect of cluster headache is its tendency to occur regularly at particular times. Clusters tend to occur during the summer and winter solstices, when days are either longest or shortest. In addition, the headaches tend to favor certain times of day: Patients are most vulnerable just after falling asleep, between the hours of 1 and 2 a.m., and around 9 p.m. and 3 p.m. The strange rhythms of cluster headache may be due to dysfunction of the hypothalamus, one of our “rhythm centers” in the brain. This structure shows some abnormalities in patients on functional MRI (fMRI) scans.
Men describe the pain of cluster headache as an “auger in the eye.” Out of desperation, one of my patients would take a dull object such as rolling pin and strike the back of his head repeatedly when the attack struck. “Anything,” he told me, “to distract me from the pain.”
Unlike migraine patients, who prefer to lie still with the headache in a quiet, dark room, cluster headache patients will pace and rock and wander the house restlessly, trying to outpace the driving pain.
Because cluster headaches are much rarer than migraine or tension headache, this type of head pain is not often diagnosed for months or even years. But it’s important to recognize cluster, because many patients can be helped with treatment. An acute attack responds to many of the medications we use for migraine headache, including the triptans and ergotamines. Breathing 100 percent oxygen helps many patients if it’s given early in an attack.
There are also effective preventive medications, such as steroids, calcium-channel blockers and medications in the anticonvulsant classes. Patients who do not respond to these therapies may be candidates for surgical intervention – such as occipital nerve stimulators or even deep brain stimulators that influence the hypothalamus.
Dr. Tarvez Tucker is an associate professor of neurology in the University of Kentucky College of Medicine and director of the UK HealthCare Headache and Pain Clinic.