Pearls & Oy-sters: Trigeminal autonomic cephalalgias

Abstract

The trigeminal autonomic cephalalgias (TACs) are a group of primary headaches that are characterized by unilaterality of pain, a relatively short duration of symptoms, and associated ipsilateral cranial autonomic symptoms, such as Horner syndrome, lacrimation, and nasal congestion. Incidence is rare when compared to other primary headache disorders but diagnosis (and, more importantly, treatment) can prove to be a challenge even when presented with a typical clinical presentation. The TACs are listed in the International Classification of Headache Disorders (ICHD-II) under their own section and include the following1: 1. Cluster headache (CH) 2. Paroxysmal hemicrania (PH) 3. Short unilateral neuralgiform headache with conjunctival injection and tearing/cranial autonomic symptoms (SUNCT/SUNA) See the table for a summary of treatment options. View this table: Table Treatment recommendations for trigeminal autonomic cephalalgias listed in order of preference ### Pearl. All cluster headaches need to be treated with abortive, transitional, and preventive therapies. ### Oy-ster. The average time it takes for a patient with CH to be correctly diagnosed is 6.6 years. The average number of physicians seen prior to correct diagnosis is 4, and the average number of incorrect diagnoses prior to a diagnosis of CH is also 4.2 CH has a very typical clinical presentation and for this reason, the aforementioned “oy-ster” is unacceptable as patients suffer needlessly. Cluster sufferers will attest to thoughts of suicide, as the pain is extremely severe, and CH is often dubbed a “suicide headache.” CH comes in 2 epidemiologic forms. Episodic cluster, the more common form, is characterized by attacks that occur daily during a cluster period, the period of attacks generally lasting 1–3 months, and followed by months or even years of remission before recurring. In chronic cluster, attacks occur for more than 1 year without remission, or with remissions lasting less than 1 month.1 Attacks are strictly unilateral with associated ipsilateral …