Medication Overuse Headache or Cluster Headaches? 2023
Cluster headache—the worst headache in the world.
Cluster headaches are often confused by patients with migraine without aura. The patient will usually state they have “Cluster headaches” because a previous doctor told them that. It is not often true and their history will commonly reveal a story of the patient experiencing a previous Migraine alias, like Sinus headache, and then multi drug overtreatment giving them medication overuse headache.
How do you tell the difference between these two headache types?
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.
Cluster headaches are more severe than the chronified Migraine headaches that come with Medication Overuse Headache (MOH). CH are always one-sided and located near the eye, whereas MOH are usually one-sided but may be behind one eye, all over the head, or in the neck.
Nausea, vomiting, photosensitivity, and sonophobia are mainly found with MOH while CH has eyelid drooping, nasal congestion, pupil smallness and eye redness which is lacking in Migraine.
Cluster Headaches come in “cluster cycles” lasting 6-12 weeks and then stopping while Migraine patients who over treat may have continuous all day long, every day, mild to moderate headaches with pain spikes severe several times a day which may last for weeks, months, or years.
Differences in attacks
Cluster headaches are very severe, quick onset, within 15-20 minute, one sided headaches which consist of pain around the eye, temple, or cheek lasting 20-40 minutes. They usually come on one side of the head only.
Migraine headaches may come on over half an hour or two but may last 4 to 72 hours and commonly will switch sides between attacks.
Cluster headache has characteristic symptoms such as: drooping of the upper eyelid, smallness of one pupil, sweating above the eye, redness of the eye, tearing of one eye, nasal congestion or drainage of clear fluid.
Horner syndrome with Cluster Headache. Right eye Small pupil, lid droop.
Migraine doesn’t have these features.
Cluster patients can’t get still and they get up and pace around the room. Migraine patients usually lie down and don’t like to be up and about.
Nausea, vomiting, and sensitivity to light and sound may occur with cluster headache, but are not as prominent as that which occurs with migraine.
Cluster headache persons have family members with migraine, just like migraine patients commonly have a history of migraine in their family.
Cluster headache doesn’t usually come in the family.
Cluster headache predominates in men, four times more than in women.
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Time to onset
The onset to peak of cluster headache is very quick—often in minutes. The headaches may track the clock, coming at the same time every day and they may characteristically occur one to two hours after going to sleep.
Aggravating features
During the cluster period drinking alcohol, nitroglycerine, or histamine may aggravate the headache, but not at other times. The patients often have a driven, type A workaholic nature.
Clinical differences
As noted by the description of migraine and cluster headache, they really are very different neurologic problems. Migraine and medication overuse headache are very common in the clinic, while cluster headache is relatively rare.
Since cluster headaches may occur daily or multiple times a day, for several months, they are confused with medication overuse headache which also may come daily, but sometimes every day for 6 months or several years which only comes with chronic cluster.
The onset to peak time for cluster headache which is usually minutes, is different from migraine which make take an hour or two to max out to the peak. Also cluster headache has true headache free times between the attacks, which is rare with medication overuse headache patients who usually always have some mild grade 1-4 headache present, and then the severe headache starts from there.
Also cluster headaches are typically locked onto one side of the head and usually don’t switch sides, while migraine amped up to medication overuse headache may switch sides and commonly comes in the back of the head or the neck on one side.
The other autonomic features of cluster headache, such as tearing, eyelid drooping, injection of the conjunctiva on one side, one side of the head nasal dripping and forehead sweating, should be a giveaway to the cluster pattern.
Lastly, the fact that cluster headaches may occur locked into certain times, like every night at 2:00 AM, or at 10:00 PM, should make the penny drop for the diagnosis of cluster headache.
Medication Overuse Headache
There is an epidemic of clinical cases of migraine in persons who over treat. It is rare for cluster patients to over treat, but it happens rarely and there are published articles about that.
A careful medication history should be taken of all drugs, including the amount of caffeine taken and supplements.
Medication Overuse Headache—too many pills.
Treatment response
The treatment response is different for cluster and medication overuse headache. Injectable sc sumatriptan, Intramuscular DHE, Migranal, nasal spray sumatriptan, or rizatriptan acutely may help acute treatment for cluster headaches.
DHE as injection and Migranal NS are commonly used acutely to treat Medication Overuse Headache.
Medication limits
Migraine patients should limit all painkillers and caffeine to no more than 2 days a week. Caffeine is the number 1 drug that aggravates medication overuse headache in America, while in Germany it is Tylenol (acetaminophen).
Starbucks, Starbucks, where’s the Starbucks?
The International Headache Society listed amounts of drugs taken which might cause medication overuse headache are:
Triptans or Ergotamine intake >10 days/month (like sumatriptan)
Non-opioid simple analgesics >15days/month (aspirin, Tylenol, caffeine, or Advil)
Opioids or Analgesics combined with barbiturates >10days/month
Patients who develop Medication Overuse Headache frequently have either frank, acknowledged migraine, or rarely tension type headache, or occult previously undiagnosed migraine with migraine features—Sinus headache, Menstrual headache, one-sided headache, throbbing, severe headache level 5-10 on a scale of 1-10, hungry headache, motion sickness, headaches with nausea and/or vomiting, headaches with sensitivity to light and sound.
Patients with these features present to the doctor with Chronic Migraine.
Summary
Differentiating between Cluster headaches and chronic Migraine due to medication overuse is important for headache treatment.
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All the best.
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Britt Talley Daniel MD
