Carotid dissection mimicking a new attack of cluster headache

Abstract

BackgroundSymptomatic cluster headache (CH) secondary to internal carotid artery dissection (ICAD) has been frequently reported, however, as far as we know, the coexistence of episodic CH and acute symptomatic CH secondary to ICAD has not.Case reportA 39 year-old man, affected by episodic CH since the age of 19, presented an atypical headache associated with his usual autonomic symptoms. After a series of negative tests, MRA eventually revealed dissection of the right distal internal carotid artery.Discussion and conclusionsThe coexistence of episodic CH and acute CH symptomatic of ICAD in our patient suggests that, at least in some cases, CH and ICAD may be different expressions of a common underlying cause: hidden vessel wall damage. When risk factors and the change - though partial - of clinical features suggest symptomatic cases, CH patients have to be strictly monitored over time. Given the lack of a gold standard investigation for dynamic diseases such as dissections, these patients require multimodal diagnostic investigation over time, even in cases where exams are normal at onset.

Symptomatic Trigeminal Autonomic Cephalalgias

“…We found 23 cases with a cluster headache-like phenotype in 23 articles [ 2 , 5 , 6 •, 7 – 10 , 11 •, 12 – 26 ]. We excluded 3 patients, as they did not fulfil the ICHD-III criteria beta version, all having an attack duration of more than 3 h [ 18 , 23 , 25 ].…”

“…Multiple sclerosis was found in two, of whom both became pain free under verapamil or prednisone, which are used as prophylactic cluster headache medication and therefore are not strictly aiming at the underlying lesion [ 2 , 21 ]. Another patient had an internal carotid artery dissection, but the outcome after treatment remained unclear [ 6 •]. Other diagnoses in this category are as follows: recurrent posterior scleritis and a specific meningitis (treated with prednisone), post-operative cluster headache (lens phacoemulsification and intraocular lens implant), an angiomyolipoma, and an ipsilateral macroprolactinoma [ 5 , 7 , 15 , 20 ].…”

“…An intracranial or extracranial dissection was reported in only 1 of the 19 cluster headache patients. This patient was diagnosed with cluster headache several years before he experienced a cluster headache attack with prolonged duration, which was probably caused by a carotid dissection [ 6 •]. Dissection as a cause for cluster headache is rare but has been reported in earlier reviews [ 4 , 50 ].…”

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.…”

Carotid dissection presenting as a prolonged cluster-like headache in a patient with episodic cluster headache

“… 3–8 ICAD complicating pre-existing episodic cluster headache was only once reported and represents a diagnostic dilemma. 4 Carotid dissections may be missed in ultrasound examination, 9 and the MRI sequences needed to discover ICAD (MR angiography, T1 axial cervical MRI with fat saturation) are usually not included in routine MRI examinations. 2 6 Headache secondary to ICAD may even respond very well to sumatriptan, posing another diagnostic challenge.…”