Letters Cluster headache

Authors’ reply to Litwin and Malhotra

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3551 (Published 22 May 2012) Cite this as: BMJ 2012;344:e3551
  1. Alexander D Nesbitt, research fellow1,
  2. Peter J Goadsby, professor of clinical neurology2
  1. 1Surrey Sleep Research Centre, University of Surrey, Guildford, Surrey GU2 7XP, UK
  2. 2Department of Neurology, University of California, San Francisco, CA 94115, USA
  1. a.nesbitt{at}surrey.ac.uk

We welcome Litwin and Malhotra’s list of painful ophthalmic conditions that may resemble some elements of a single attack of cluster headache.1 2 We also agree that patients with these conditions may experience these symptoms on more than one occasion. Their suggestion that neuroimaging is warranted to exclude secondary causes of cluster headache-like pain is echoed in our manuscript.

However, it would be highly unusual for these conditions to cause repetitive, extremely stereotyped, attacks that occur at least once a day, every day, that last between 15 minutes and three hours only, and which cluster together into bouts that last several weeks. Cluster headache attacks occur without any reduction in visual acuity or halo effects but can cause unilateral photophobia in around half of patients.

The cranial autonomic features demonstrated in our clinical photograph show a patient mid-attack and would be seen only if a practitioner attended the patient during an attack. This photograph should be used as a prompt to remember to ask patients during the consultation about cranial autonomic features that accompany attacks. It should be viewed in conjunction with the video hyperlinked in the Additional Educational Resources box, which shows the psychomotor agitation that is characteristic of a cluster headache attack.

We of course agree that many serious causes of an acutely painful red eye require urgent ophthalmic referral. However, we re-emphasise that an accurate history to elucidate the clinical diagnostic features, as set out in our review, is almost always sufficient to make a correct diagnosis of cluster headache. In this scenario, additional ophthalmic assessment only contributes to an unnecessary delay in treatment.3


Cite this as: BMJ 2012;344:e3551