Internal carotid artery dissection presenting as cluster headache

Abstract

Cluster headache (CH) is a clinical entity characterized by strictly unilateral head pain attacks accompanied by ipsilateral autonomic phenomena. The attacks are severe, short-lasting (15-180 minutes), and may occur several times a day 1 . Symptomatic CH cases have been described in association with different kind of lesions located in the middle fossa, near the sellar or parasellar structures although lesions of the internal carotid artery (ICA) were also described: aneurysma of ICA and internal carotid artery dissection (ICAD) 2 . We report a patient with symptomatic CH secondary to ICAD, and complete remission of his symptoms with usual treatment for CH. We obtained informed constent from the patient for publication. CaSeA 53-year-old white man presented to the emergency room of Hospital Israelita Albert Einstein with 10-day history of recurrent right peri-orbital headache. Headaches were sudden, severe, pulsating, of thirty minutes duration and occurred once or twice a day. Headache was accompanied by ipsilateral ptosis, conjunctival injection, lacrimation and nasal stuffiness. He was on treatment for mild hypertension with hidroclorotiazide 25 mg once a day. Examination during headache revealed right Horner's syndrome with partial ptosis and miosis, accompanied by ipsilateral lacrimation, eyelid edema and conjunctival injection. After this episode, he remained with mild right ptosis. The remaining cranial nerves and neurological examination were normal.The above features satisfied criteria "A to D" for CH of the International Classification of Headache Disorders (number, site and duration, accompanying symptoms, frequency of headaches) 1 . Criterion E stipulates that other causes for the headache must be ruled out. We therefore performed further investigations. Computed tomographic imaging of the brain was normal. Fat supression T1-weighted magnetic resonance imaging of the carotid canal level displayed high signal compatible with blood products within the wall of the right internal carotid what was sugestive of arterial dissection (Figure).He was admitted in our critical care unit and complementary investigation was performed. Blood cell count, erythrocyte sedimentation rate, coagulogram, protein C and protein S, lipidogram were normal. Results from a heart survey, including Holter's monitor and echocardiography, were normal.The patient was anti-coagulated. Verapamil and prednisone were initiated as prophylactic therapy for cluster headache in our patient. There was complete resolution of headaches in one week and the patient was entirely asymptomatic at follow-up six months later.

Carotid dissection mimicking a new attack of cluster headache

“…However, anamnestic and clinical data could be unable to support the differential diagnosis, as reported by Godeiro-Junior et al [5]: in their report ICAD presented with CH-like pain, Horner syndrome and other autonomic symptoms. For these reasons, further investigations are mandatory.…”

“…Either in CH or in ICAD, rarely, it could be found also unilateral tearing, conjunctival injection and rhinorrhea due to parasympathetic dysfunction [4,5]. …”

“…In fact, many cases of symptomatic CH secondary to internal carotid artery dissection (ICAD) have been reported [1-5]. However, to our knowledge, the occurrence of acute symptomatic CH secondary to ICAD in a patient affected by episodic CH has never been reported.…”

Post-Operative Cluster Headache Following Carotid Endarterectomy

“…In a recent review on secondary cluster headache, 11 out of 63 patients had a carotid/vertebral dissection [3]. A review in 2007 identified 6 patients with ICA dissection presenting with cluster-like features [10] and several more cases have been described [11,12,13,14,15]. In all these patients, headache attacks disappeared within 2 months.…”

Symptomatic cluster headache: a review of 63 cases

“…Persistent ptosis and miosis between headaches are widely accepted as features of primary CH. Duration of headache more than three hours, absence of daily periodicity, neck pain, and no worsening from alcohol should increase the degree of suspicion of dissection (Razvi et al 2006; Godeiro-Junior et al 2008). …”