Cluster headache and vertigo

N Vijayan

CEPHALALGIA Vijayan N. Cluster headache and vertigo. Cephalalgia 1990;10:67-70. Oslo. ISSN 0333-1024 The term "cluster vertigo" was originally used by Gilbert to describe episodes of vertigo in patients with Ménière's syndrome. Since these patients also had co-existing cluster headache, he suggested that both disorders could have had a common pathophysiology. There is no evidence in the literature for an increased incidence of Ménière's syndrome in cluster headache patients, so the argument that cluster headache and Ménière's syndrome may have a common pathogenesis cannot be supported. Subsequent authors have used the term "cluster vertigo" to denote a variant form of cluster headache and have confused the matter further. This was not the intention of the original author. The terminology is misleading and should not be used to describe a sub-type of cluster headache. A case of cluster headache with accompanying vertigo is described as a contrast to the patients described by Gilbert in whom headache and episodes of vertigo occurred independently. ' Cluster headache, cluster vertigo, Ménière's syndrome N Vijayan, Headache and Neurology Clinic, 2600 Capitol Ave, 211, Sacramento, CA 95816, USA; Accepted 15 January 1990 The term "cluster vertigo" has been used in the headache literature to denote a variant form of cluster headache (1). However, it is not included in the new "Proposed Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain" compiled by the Headache Classification Committee of the International Headache Society (2). This terminology originated from two publications by Gilbert (3-4) in which he described patients who had Ménière's syndrome with grouped episodes of vertigo (which the author called "cluster vertigo") and episodic cluster headache. These two symptom complexes were independent of each other. However, because of their intermittency and certain other similarities (which are discussed later), the author felt that both these syndromes had a common underlying pathogenesis, namely "recurrent focal vasodilatation" in the appropriate anatomical locations. Unfortunately, some of the subsequent publications used the term "cluster vertigo" as a specific sub-type of cluster headache. This review of the subject is to clarify the terminology. In addition, two cases are reported, one exemplifying the type described by Gilbert and another in which vertigo was a concomitant symptom of cluster headache. Case of Ménière's syndrome and episodic cluster headache

This 49-year-old male began experiencing episodes of vertigo, nausea, vomiting and tinnitus at the age of 22. The episodes progressively worsened, resulting in partial hearing loss on the left side. Investigations confirmed the diagnosis of Ménière's disease. In 1981 surgery of the left ear to control these episodes resulted in total deafness on the left. He was symptom-free for five years before developing a low-grade but persistent dizzy feeling. At the age of 39 he had a brief spell of headaches. He could not recall the exact details of those headaches, but the basic characteristics were the same as those he developed later. In March 1989 he had one single headache lasting for 30 min. Recurrent, almost daily headaches began in July 1989 with one to six per day, some of them nocturnal. The pain was located in the left periorbital, temporal, parietal and occipital areas with some involvement of the cheek. Pain peaked in 5 to 10 min, lasting for 30 to 45 min on average, and was described as sharp, piercing, throbbing and severe. There was associated conjunctival injection, tearing, nasal stuffiness and ptosis of the upper lid without meiosis. Neurological

examination was normal except for hearing loss on the left side. MRI scan of the brain was normal. The headaches responded well to a combination of ergotamine and methysergide and at the time of writing were in remission. Comments This patient had typical episodes of Ménière's syndrome which required surgical destruction of the internal ear with relief of symptoms. Subsequently, independent of the episodes of vertigo, the patient developed episodic cluster headache. This combination is what Gilbert described in his two publications. Summary of Gilbert's cases Gilbert reported three cases of "Ménière's Syndrome and Cluster Headaches" in 1965 and added four more in 1970 under the title "Cluster Headache and Cluster Vertigo" (3-4). His first patient was a 43-year-old male who experienced grouped episodes of vertigo every six months with progressive hearing loss on the left side between the ages of 28 and 37. Investigations revealed left hearing loss and recruitment. These attacks ceased spontaneously and he developed typical episodic cluster headaches lasting for four to six weeks with remissions of six weeks to six months. The second patient was a 47-year-old male who at the age of 38 had had attacks of vertigo occurring in groups associated with tinnitus on the right side. Neurological investigations were normal. These attacks subsided without any residuals in eight months. At the age of 47 he developed episodic cluster headache on the left side associated with typical autonomic features lasting for five weeks. No further follow-up was recorded. The third patient was a 31-year-old female who developed episodes of frequent vertigo and vomiting at the age of 29. There was nystagmus on examination during these attacks. The symptoms lasted for two months. She noticed intermittent tinnitus on the right side. Two years later she developed recurrence of episodic vertigo but without hearing loss or tinnitus. During the second episode she also developed typical episodic cluster headache on the right side. To quote Gilbert: "the headaches and attacks of vertigo usually occurred quite independently, but they could occur simultaneously". Investigations revealed bilateral decreased hearing and recruitment. The fourth and fifth patients had only episodes of vertigo and their symptoms improved on methysergide. The author used this observation to support his conclusion that both these disorders had a similar underlying pathophysiological basis. The sixth patient was a 50-year-old male who had had episodic right-sided cluster headache for 20 years. At the age of 30 he had a six-week period of vertigo which was worse while lying down; this was diagnosed as Ménière's disease. He had another period of vertigo lasting for three weeks at the age of 46. Hearing was decreased bilaterally. It was stated by Gilbert that "he clearly was experiencing recurrence of cluster headaches at the same time that he was experiencing cluster vertigo ". However, there was no indication that the headache and vertigo occurred simultaneously. The seventh patient just had episodes of vertigo which responded to methysergide. Comments on Gilbert's cases Four of the seven patients described by Gilbert had episodic cluster headache and, independently, symptoms characteristic of Ménière's syndrome. He used the term "cluster vertigo" to describe Ménière's syndrome because vertigo was occurring in clusters just as the headaches were occurring in clusters. Patients 3 and 6 are described as having headache and vertigo during the same time frame but there is no indication that these two symptoms occurred simultaneously. The remaining three patients had Ménière's disease which responded to methysergide therapy. Discussion Gilbert used the term "cluster vertigo" to describe episodes of vertigo occurring in Ménière's syndrome. Subsequent authors

have used it to denote a variant form of cluster headache because Gilbert's patients also had episodic cluster headache. It is clear from his two publications that Gilbert intended to point out the fact that Ménière's syndrome and episodic cluster headache could co-exist in a small number of patients. He detailed some of the common features between these two syndromes and postulated that they could both have a similar pathophysiological mechanism. To quote the author: "in contrast to classical migraine, the syndrome of recurrent paroxysmal focal vasodilatation reported herein demonstrates later age of onset (fourth to fifth decades), lack of family history of the disorder, absence of vasoconstrictive aura, marked unilaterality of each component, and clustering of attacks. Most critical in relating Ménière's syndrome to a type of vascular headache is their very close similarity in form and temporal pattern of attacks in the same individual; such a similarity of Ménière's paroxysms and cluster headache attacks is exemplified by the cases in this report" (3). He believed that a focal vasomotor abnormality was the common denominator in these two disorders. He used the positive therapeutic response to methysergide in three patients with Ménière's syndrome as a point in favour of this hypothesis. He never mentioned that these patients had a variant form of cluster headache. He used the term "cluster vertigo" to describe the grouped episodes of vertigo typically seen in Ménière's syndrome. His cases were similar to the first case described here. It is possible that there is a small percentage of cluster headache patients in whom Ménière's syndrome could be co-existing as described by Gilbert. However, this has not been documented except in his four patients and the one case described here. It is possible that specific questioning of cluster headache patients for a history of vertigo might uncover such an association more often. Kudrow did not observe any relationship between cluster headache and Ménière's syndrome in the large series of cluster headache patients he studied (1). If such an association is established, one could consider the possible similarity in the pathogenesis of these two syndromes, as suggested by Gilbert. Any discussion of a common pathogenesis will remain purely speculative until such an association is established. Use of the term "cluster vertigo" to describe a variant of cluster headache is a typical example of how terminology is applied to denote a meaning the original author did not intend for it. Based on this information, the term "cluster vertigo" should not be used to describe a variant form of cluster headache at this time. Case of cluster headache with vertigo

This 40-year-old man first experienced headaches at the age of 32. At the beginning these occurred in groups during the fall and winter seasons. By the age of 38 his headaches were occurring all the year round but were less frequent during the summer months. Headache frequency was one per day and most headaches occurred in the early morning hours. The majority of the headaches were preceded by a feeling of disequilibrium and subjective true vertigo for a few minutes. All headaches were associated with disequilibrium and vertigo during the painful phase whether these symptoms preceded the headache or not. All the symptoms subsided at the same time. He never experienced disequilibrium or vertigo during a remission period. There was no tinnitus or hearing loss associated with headache. Headache always occurred on the right side. Pain was confined to the supraorbital, peri- and retro-orbital areas and was described as an ache with pressure to begin with and later developing a pulsating quality. The intensity peaked in 45 to 60 min and generally subsided in 90 min. It was always severe and disabling. The patient usually paced around during the headache and there was associated conjunctival injection, tearing, nasal stuffiness and discharge on the fight side. There was no ptosis or meiosis. There was some nausea but no vomiting. Alcoholic beverages would consistently trigger a headache in 20-30 min. Neurological

examination, audiological evaluation including ENG and caloric testing, brain stem auditory evoked potential, MRI scan of the brain and EEG were normal. The patient was treated with a combination of verapamil and sublingual ergotamine. Ergotamine controlled the individual headache very well. He entered a period of remission three weeks after treatment with verapamil was initiated. Vertigo and disequilibrium also subsided. He was gradually weaned off verapamil after five months. The headaches recurred in the same location after one year of remission. These had similar characteristics as before including disequilibrium and vertigo occurring prior to or during the headache. Examination remained normal and he was treated with the same combination of drugs and responded again by entering a period of remission. Comments This patient has a history of episodic cluster headache evolving into chronic cluster. The unusual feature is the sense of disequilibrium and vertigo, often occurring a few minutes prior to the onset of headache and continuing throughout the headache phase in a consistent fashion. This can be considered as an associated neurological symptom and appears to be part and parcel of the headache, unlike Gilbert's cases where there was co-existence of two distinct disorders occurring independently in the same patient. When this patient was first seen, a diagnosis of cluster vertigo was made because of the mistaken assumption that this term denoted the occurrence of vertigo along with cluster headache. However, when the original articles were reviewed, it became apparent that this patient's history was quite distinct from what was described by Gilbert (3-4). In this particular case, vertigo was an accompaniment of cluster headache. No similar case has been documented in the literature so far. For the present, the occurrence of vertigo and disequilibrium along with cluster headache in this single patient has to be considered as a unique and isolated phenomenon. Publication of similar cases, if encountered by others, would be worth while in order to document the existence of such an association. Conclusion

The term "cluster vertigo" was originally used to describe groups of vertigo occurring in patients with Ménière's syndrome. Unfortunately, this terminology was later used to describe a variant form of cluster headache because the four patients originally described with Ménière's syndrome also happened to have independent episodes of cluster headache. This terminology is confusing, easily misinterpreted, and should not be used in classifying cluster headache. Acknowledgement.-I am grateful to Dr. Lee Kudrow for his helpful suggestions. References

1.

Kudrow L. Cluster Headache: Mechanisms and management. Oxford Medical Publications 1980

2.

Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache classification committee of the International Headache Society. Cephalalgia 1988;8(suppl 7)

3.

Gilbert GJ. Ménière's syndrome and cluster headaches: Recurrent paroxysmal vasodilatation. JAMA 1965;191:691-4

4.

Gilbert GJ. Cluster headache and cluster vertigo. Headache 1970;9:195-200

Cluster headache and vertigo.

The term "cluster vertigo" was originally used by Gilbert to describe episodes of vertigo in patients with Ménière's syndrome. Since these patients al...
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