De Novo Cluster Attacks after Intravenous Nitroglycerin Therapy (P03.215)

Abstract

Objective: To describe a unique patient who experienced attacks of cluster headache (CH) after the administration of intravenous nitroglycerin (NTG) for Prinzmetal9s angina. Background NTG is widely utilized in the treatment of angina, and headache is a well-known side effect of this medication in both patients with and without a history of a primary headache disorder, including CH, which likely is from vasodilatory mechanisms. Patients with a prior history of primary headache disorders including CH may experience a delayed attack, characteristic of their typical headache, occurring up to 8 hours after stopping NTG infusion, likely secondary to direct neuronal and inflammatory mechanisms. To our knowledge, no patient has been described to have first onset CH attacks after NTG administration. Design/Methods: Case report from a tertiary medical center. Results: A 43 year old woman who previously only experienced infrequent episodic tension-type headache presented to our hospital with recurrent episodes of severe chest pain over 2 days, and was thought to have an ST-elevation myocardial infraction. Emergent cardiac catheterization revealed severe coronary vasospasm, consistent with Prinzmetal9s angina, and was treated successfully with an intravenous NTG infusion and subsequently verapamil. She subsequently experienced her first ever CH attacks, both within minutes after NTG initiation and 16 hours after its discontinuation. Both attacks were identical and characterized by 60 minutes of excruciating left orbital pain associated with moderate ptosis. Her interictal neurological examination, MRI and MRA of the brain were normal, and she experienced no subsequent attacks. Conclusions: This patient experienced de novo CH attacks from intravenous NTG. The delayed onset of CH attacks strongly suggests a direct neuronal or inflammatory mechanism rather than attacks occurring from intracranial vasodilation. Perhaps a brief cluster period itself was brought on by NTG, which was rapidly suppressed by both withdrawal of the agent and institution of verapamil. Disclosure: Dr. Agopian has nothing to disclose. Dr. Robbins has nothing to disclose.