Cluster headache is a strictly unilateral headache that occurs in association with autonomic symptoms. Stress is a recognised precipitant of migraines, but not of cluster attacks. We describe the case of a patient having migraine for years, in whom extreme emotional stress triggered cluster headache attacks.

Background

Neuroimaging has contributed considerably to the knowledge about the neurobiology of cluster headache. Activation in the region of the posterior hypothalamus is observed,¹ coinciding with subtle structural abnormalities in the same region.²

Genetic studies indicate an autosomal dominant inheritance with low penetrance and an increase in risk of 4–18 times for cluster headache in first-degree relatives when compared with the general population.³

Although the triggers for individual episodes are well recognised, the most important ones being nitroglycerin,⁴ alcohol,⁵ increased body heat and exertion,⁶ this is not the case for the triggers for bouts.

Case report

A man, about 50 years old, had been treated by us for a decade. He had experienced migraine without aura from his early teens. He had a positive family history of headache, with both his parents and two siblings having migraine. A typical migraine episode consists of pain that is mostly unilateral but with the side changing, periorbital or temporal, and sometimes bifrontal, accompanied by nausea, phonophobia, photophobia and often osmophobia. Our patient never had any autonomic signs accompanying his migraine episodes. The headache would typically be severe, with a throbbing character and exacerbated by movement. The episode lasted from 1 hour, when treated, to several days …