Mark W. Green, M.D.
Columbia-Presbyterian Headache Center
New York, NY
A 48-year-old male came to my office with pain so severe he was contemplating suicide. For the past four weeks, he had been awakened each night with a severe pain deep in his right cheek and upper teeth. He was unable to lie in bed during these attacks. Instead, he paced relentlessly, rocking and crying. After an hour or so, the pain would resolve. However, upon returning to sleep he would again be awakened by another attack.
He noted that his right nostril was congested and when he blew his nose, a clear liquid emerged. He had undergone dental extractions of right upper molars, a procedure which did not afford him any relief. He was angry, depressed and sleep-deprived, and told me that if I did not help him, he would "do something to himself."
Discussion This unfortunate man has a variant of cluster headache that used to be known as the "lower half syndrome," because the symptoms strike the cheek and mouth area rather than the eyes, temples and forehead.
Cluster headache is perhaps the most painful of the primary headache syndromes (those not due to structural pathology). The most striking feature of this type of headache is its periodicity, or clustering of attacks over time. Sufferers are headache-free, then experience daily attacks lasting weeks to months. They then experience prolonged remissions of months to years. Since this was this man's first "cluster period," the periodicity was not yet evident. During the cluster period, one or more attacks lasting twenty minutes to three hours are endured. The pain of cluster is always one-sided and tends not to switch sides. Tearing of the eye and stuffiness of the nose are associated with the attacks, always on the same side as the pain. Sufferers are more likely to be males.
Although cluster is commonly confused with migraine, there are striking differences. Cluster pain is typically described as a deep boring pain behind the eye and temple, unlike the pulsating pain of migraine. The onset of cluster is faster than migraine, often reaching full intensity within minutes of onset. Attacks are also somewhat shorter than migraine, which typically last four to seventy-two hours. The behavior of cluster headache sufferers is also different from individuals with migraine. Migraineurs wish to lie quietly in bed in a cool, dark room and often encase their head in their pillow. Cluster sufferers pace relentlessly, finding it difficult to hold still. Although many headaches can be triggered or worsened by alcohol, cluster attacks almost invariably follow the use of beer or wine. Individuals with cluster are also often smokers and smoking cessation sometimes helps to relieve attacks.
The treatment of cluster differs from the treatment of migraine. Cluster headaches are best treated preventively with high doses of verapamil combined with divalproex, topiramate or lithium carbonate. Oxygen, while not helpful as a migraine treatment, often turns off a cluster attack. Sumatriptan by injection is highly effective in both migraine and cluster, but is more efficacious in cluster.
Patients with "lower half syndrome" are rarely diagnosed correctly. They commonly undergo ineffective dental and sinus procedures since they experience most of their pain in their cheeks and upper teeth. These procedures do not improve the condition. They often receive a diagnosis of trigeminal neuralgia, which is a sharp and shooting pain triggered by touching the face or chewing. Trigeminal neuralgia is treated in an entirely different way. If recognized, cluster headache, often described as "suicide headache," can be treated effectively, sparing sufferers from unnecessary impairment in their quality of life.