Tasty Morsels of EM 076 – #FRCEM Cluster Headaches

26 Jul

(Featured Image, Wikimedia Commons, JD Fletcher)

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

As summarised from Rosen’s 8th p1389 and the UK NICE Guideline on headache

Clinical Features?

  • Only headache commoner in men than women
  • classically late 20s smoker
  • alcohol thought to be a precipitant of a cluster
  • episodes from 15mins to several hours with rapid resolution
  • pain confined to trigeminal distribution
  • often features of agitation, pacing and rubbing the head
  • ispilateral autonomic features are a key
    • ptosis or miosis (remember these are mediated by sympathetic and parasympathetic systems and not necessarily a more concerning specific cranial nerve problem (typically a 3rd or a Horner’s syndrome)
    • facial sweating
    • eye is often red and watering

Recommended UK management?

  • high flow O2 is the famous one (NNT of 2 apparently)(NICE)
  • other migraine therapies seem useful
    • sumatriptan nasal or sub cut but NOT oral (NICE)
    • your dopamine agonist of choice
  • headaches will likely recur and like migraine steroids have been proposed as has verapamil to prevent recurrence (NICE states use verapamil)
  • The American Headache Society as a management guide for health professionals that largely reinforces everything above with no mention of our beloved dopamine agonists but they do add in topical nasal lignocaine drops as an option


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