Extreme restlessness, agonising pain, and clockwork timing - is there an underlying cause to regular headaches? Photo / 123RF
Extreme restlessness, agonising pain, and clockwork timing - is there an underlying cause to regular headaches? Photo / 123RF
In his regular column, Dr James Le Fanu answers your questions. This week, a reader suffers from horrendous headaches
Q. For the last couple of years I have suffered horrendous headaches always following the same predictable pattern. I wake at three in the morning with athrobbing pain over my left eye accompanied by profuse watering and blockage of the nostril on the same side. This rapidly increases to an agonising pitch forcing me out of bed to pace up and down clutching my head. Then quite suddenly, after an hour or so, it stops, leaving me completely exhausted. My doctor is sympathetic but the several powerful painkillers he has prescribed provide no relief.
A. There were, at the last count, more than 150 different types of headaches posing a significant medical challenge, not least as blood tests and scans tend to be normal and thus uninformative. Rather their accurate diagnosis relies almost exclusively on paying close attention to the sufferer’s description of the salient characteristics.
The two most common, migraines (throbbing and unilateral) and tension headaches (persistent and vice like) are familiar enough. But beyond that, detailed questioning as to the nature, quality and location of the pain, its frequency and duration is necessary to distinguish cephalgia fugax (sharp and transient) from hemicrania continua (one sided, continuous), chronic daily from medication-induced and so on.
This reader’s description is absolutely characteristic of “cluster headaches” – so called because they are grouped into clusters up to several times daily, persisting for weeks or months on end interspersed by equally prolonged periods of being symptom-free. The further typical features are their intensity, rated as the worst of any type of headache, likened to a hot poker or screwdriver penetrating the eye.
Her behavioural response of extreme restlessness is also typical as is, notes neurologist Joseph Blau, the diversionary tactic of “self trauma”– pressing a finger or thumb hard into the affected eye, hitting the forehead against a hard object (wall or radiator), applying intense heat or ice, clenching the fists so the nails dug into the palms. To complete the picture, cluster headaches are also remarkable for their clockwork regularity often occurring (as here) at exactly the same time of day or night and the associated symptoms, for as long as it lasts, of eye-watering and nasal stuffiness.
Cluster headaches are known as the "suicide headache" due to their extreme pain. Photo / 123RF
Might there be some other explanation?
No, which unfortunately does not mean that failure to pay close attention to the sufferer’s description not infrequently results in their being misattributed to some other cause. As one reader recalls: “My cluster headaches were intensively investigated over several years and I was told they were due variously to migraine, neuritis and sinusitis.” Until, dining with friends one evening, a fellow guest (and consultant physician) to whom he recounted his symptoms finally proffered the correct diagnosis.
Treatment
The severity of acute cluster headaches is impervious to the most potent of painkillers but, if surprisingly, may be alleviated by an eclectic selection of drugs. They include the anti-migraine triptans (such as sumatriptan) though, as speed of action is essential, they must be self-administered by injection or as an intranasal spray. Next, if rather bizarrely, breathing 100% oxygen through a mask will reliably abort an attack within just a few minutes. Finally, the frequency of cluster headaches can be markedly diminished by a short intensive course of steroids or, at high dosage, the blood pressure-lowering medication, verapamil.
