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Acute Headache: Hypertensive Urgency and Cluster Headache (Horton's Syndrome)

by Carlo Raj, MD
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    00:01 Let’s talk about hypertensive urgency as being a presentation of acute headache.

    00:07 Dull, bilateral ache head pain, no focal deficit, possible diminished level of consciousness if associated with reversible posterior type of leukoencephalopathy.

    00:25 Usually seen when systolic blood pressure is above 170 and the diastolic blood pressure is above 110.

    00:32 Treatment here is you need to make sure that you take care of the hypertension.

    00:36 Urgency versus your crisis, or emergency, and your crisis is the one in which you don’t mess around.

    00:43 At that point, you need to make sure that you give IV, do everything in power in which you give IV nitroprusside to take care of the blood pressure ASAP.

    00:51 Remember, we talked about hypertension urgency versus crisis.

    00:56 Here, let’s talk about a cluster headache.

    00:59 The duration becomes important.

    01:01 Abrupt in onset, peaking approximately five to ten minutes later.

    01:06 That is important.

    01:08 Pay attention to that.

    01:10 Persists for 45 minutes to 2 hours.

    01:13 And clusters, meaning to say over days to weeks.

    01:17 So it comes in these clusters, over days to weeks.

    01:22 Peak of five to ten, persists for 45 minutes to 2 hours, and comes in clusters.

    01:29 Consistently unilateral and orbital in location.

    01:34 “Doc, it feels like I have pain in my eye.

    01:38 It feels like someone is stabbing me in the eye.” Orbital location.

    01:42 Pain described is deep, intense, boring, meaning to say like a needle being put.

    01:48 So, they don’t call this being throbbing.

    01:50 Throbbing will refer to as being our giant cell arteritis.

    01:54 “Doc, I feel like these pulsations of throbbing headaches.” Boring is more like a needle, being stabbed.

    02:02 These patients are moving around the room, banging their head on the wall, screaming for medication because could you imagine putting a needle into your eye? Isn’t a good feeling.

    02:13 Nausea and vomiting are atypical, associated with lacrimal or nasal secretions.

    02:20 Who does it occur in? Young adult men.

    02:23 Usually, onset will be 30s.

    02:26 Male to female ratio, males much more so than females with cluster headaches.

    02:32 Now, suicide, an occasional complication.

    02:35 This darn headache is so bad that that patient is not able to handle and manage this by himself or herself, most likely himself, that he wishes to then kill himself due to the intense nature and predictable recurrent rate of the pain.

    02:50 That becomes important.

    02:51 Even though we just call this a headache, we understand the implications can quite literally be grave.

    02:58 Let’s take a look at management of cluster headache.

    03:00 Abortive therapy is often ineffective due to the rapid onset.

    03:04 Remember, short duration of attacks.

    03:06 So the peak is five to ten minutes.

    03:08 However, you say short duration.

    03:10 Keep that in mind, it’s all relative.

    03:12 Forty-five minutes is actually not a lot of time over a grand scheme of things.

    03:18 However, for the patient, it feels like eternity.

    03:21 “Doc, my headache feels like it’s forever.” Yes, when you’re in that type of pain, even 30 seconds is too long.

    03:29 Sumatriptan sub-Q, D.H.E sub-Q, narcotics, face mask oxygen for eight to ten liters, intranasal lidocaine to relieve some of this pain.

    03:42 Management: sumatriptan.

    03:45 Prophylactically, lithium, perhaps.

    03:48 Anti-epileptic here but this is valproic acid, and amitriptyline tends to be prophylactic with the next set of cluster headaches that might then recur.

    04:01 In summary of cluster headache: Risk factors: male, much more so, young male, 30s.

    04:07 Preventive medicine: lithium, some of your calcium channel blockers, amitriptyline, valproic.

    04:14 Signs and symptoms: unilateral boring, boring, boring.

    04:17 By boring, you know what I’m referring to now.

    04:19 I’m not saying, “Well, I’m sitting on my couch watching TV because I’m bored.” No, no, no, this is boring like you’re stabbing someone.

    04:30 Differential diagnosis: glaucoma, dissection, cerebral vein thrombosis.

    04:35 Diagnostic workup: H&P, image can rule out other diagnoses if it’s causing this type of headache.

    04:44 Otherwise, H&P.

    04:46 Treatment: we talked about sumatriptan, narcotics, oxygen.


    About the Lecture

    The lecture Acute Headache: Hypertensive Urgency and Cluster Headache (Horton's Syndrome) by Carlo Raj, MD is from the course Headache. It contains the following chapters:

    • Acute Headache: Hypertensive Urgency
    • Acute Headache: Cluster Headache

    Included Quiz Questions

    1. Treat with IV nitroprusside
    2. Treat with aspirin
    3. Massage the head
    4. Treat with IM nitroprusside
    5. Treat with sublingual nitroprusside
    1. IV nitroprusside
    2. Intranasal lidocaine
    3. Dihydroergotamine subcutaneous
    4. Sumatriptan Subcutaneous
    5. Face mask oxygen
    1. A cluster headache is typically unilateral and orbital in location.
    2. Confirmatory diagnosis of this headache is by bilateral carotid angiography.
    3. A cluster headache is throbbing in nature.
    4. Lithium is useful in the treatment of the headaches.
    5. Females often present with such headaches.

    Author of lecture Acute Headache: Hypertensive Urgency and Cluster Headache (Horton's Syndrome)

     Carlo Raj, MD

    Carlo Raj, MD


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