Cluster headache associated with acute maxillary sinusitis
A 24-year-old man presented with a 4-week history of side-locked attacks of excruciatingly severe stabbing and boring left-sided pain located in the orbit. The attacks were associated with nasal obstruction, clear nasal discharge, conjunctival injection and restlessness. There was no continuous background pain. The duration of the attacks was about 40 minutes and the frequency was 3 per 24 hours, 5 days a week. He denied taking any medications for headache.
The most likely diagnosis of this presentation is
- Temporomandibular joint (TMJ) syndrome
Cluster headache (CH) is a primary headache, by definition not caused by any underlying structural pathology and belonging to the group of trigeminal-autonomic cephalalgias.1 CH is the most frequent syndrome in this group. The characteristic symptoms are strictly unilateral head pain (mainly around orbital and temporal regions) and associated ipsilateral cranial autonomic features. The headache usually lasts 45-90 minutes, but can range between 15-180 minutes. A circannual and circadian pattern is typical. Symptomatic cases of CH have been described, for example tumors, particularly pituitary adenomas, malformations and infections/inflammations.4
There was no history of headache
His vital signs, physical examination, and neurological examination were normal. Local tenderness over the sinuses was not found. Laboratory testing was normal. He satisfied the revised International Classification of Headache Disorders criteria for cluster headache.
A diagnosis of CH was made and subcutaneous sumatriptan as well as oxygen 100% (7 L/min) were prescribed. The patient responded to subcutaneous sumatriptan/oxygen with relief within 20 minutes. A follow-up was planned. An otologist consultation was performed to rule out an acute sinusitis. Low-dose computer tomography scan after 2 weeks displayed a left sided acute maxillary sinusitis. A sinus puncture was performed and it displayed acute inflammation/high leukocyte count. Bacterial culture displayed Haemophilus influenzae. The headache attacks resolved completely after treatment with antibiotics and sinus puncture. A low-dose computer tomography scan was repeated after 6 weeks and displayed normal findings. The prescribed medication was discontinued. No additional treatment was given. He remained headache-free and had not experienced any headache attacks at follow-up after several years.
The case revealed an acute maxillary sinusitis. The patient satisfied the revised International Classification of Headache Disorders criteria for CH. The headache attacks resolved completely after treatment and the patient also remained headache free at follow-up after several years. An alternative explanation could be the following: during CH attacks autonomic symptoms, including nasal congestion, are commonly observed. Nasal congestion could predispose the patient to develop an acute sinusitis. A spontaneous remission of an episodic CH could be misinterpreted as being an effect of the antibiotic treatment. The response of the headache to sumatriptan and other typical CH medications does not exclude a secondary form.2,3 The most widely accepted theory of primary CH is characterized by hypothalamic activation with secondary activation of the trigeminal-autonomic reflex, probably by a trigeminal-hypothalamic pathway.4 Magnetic resonance imaging is preferred for imaging in CH cases because of its greater sensitivity to vascular disease, tumor, demyelinating disease, and infections/inflammations.5,6
Cluster headache is a primary headache by definition not caused by any known underlying structural pathology. Neuroimaging, preferably contrast-enhanced magnetic resonance imaging including sinuses should always be considered in patients with cluster headache despite normal neurological examination. Acute maxillary sinusitis can present as cluster headache.
- Headache Subcommittee of the International Headache Society (2004) the international classification of headache disorders, 2nd edition. Cephalalgia 24(suppl 1):9–160
- Ad Hoc Committee on Classification of Headache (1962) Classification of headache. JAMA 179:717–718
- Testa L, Mittino D, Terazzi E, et al. (2008) Cluster-like headache and idiopathic intracranial hypertension: a case report. J Headache Pain 9:181–183
- Cittadini E, Matharu MS (2009) Symptomatic trigeminal autonomic cephalalgias. Neurologist 15:305–312
- Wilbrink LA, Ferrari MD, Kruit MC, et al. (2009) Neuroimaging intrigeminal autonomic cephalgias: when, how, and of what? Curr Opin Neurol 22:247–253
- Mainardi F, Trucco M, Maggioni F, et al. (2010) Cluster-like headache. A comprehensive reappraisal. Cephalalgia 30:399–412