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Keywords:

  • headache;
  • aneurysm

Abstract

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES

We report a 55-year-old man presenting with symptoms of cluster headache, including throbbing pain behind the left eye, tearing, and rhinorrhea. Magnetic resonance imaging and magnetic resonance angiography revealed no abnormalities. Two days of intravenous dihydroergotamine resolved his pain. His headaches were somewhat relieved with a treatment regimen of 100 mg of imipramine each night, 40 mg of propranolol twice a day, 250 mg of divalproex three times a day, and dihydroergotamine nasal spray for breakthrough headaches. Two months later, the severity of his pain increased dramatically. Repeat imaging revealed a large thrombosed left posterior communicating artery aneurysm. Following obliterative surgery, his headaches are infrequent and mild and resemble tension headaches. Dramatic changes in headache characteristics can be an indicator of aneurysmal enlargement and thrombosis. This case illustrates the importance of repeat imaging when a patient's headache significantly worsens.


CASE HISTORY

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES

A 55-year-old man referred for cluster headache reported stabbing or throbbing pain behind the left eye. The pain would characteristically radiate to the temple and sometimes back to the occiput. It would last between 15 minutes to 1 hour and tended to occur at night, often 6 to 10 times. All of his headaches were around the left eye with a similar pattern and were accompanied by tearing and slight redness of the eye. The patient would move about and engage in activities that he hoped would stop the headaches. He reported a 10-year history of these bouts of headache, which tended to come and go. He was a good observer and gave no hint of a regular periodic sequence to the headaches, but all were related to the left eye.

He had seen another neurologist 1 year previously at which time MR imaging and MR angiography revealed no abnormalities (Figure 1). He was seen by an ophthalmologist and was said to have nonocular headaches that were probably vascular in origin. No third nerve or other abnormality was recorded in this eye examination. The neurological examination, particularly visual fields, fundi, eye movement, and cranial nerve function, was normal. He was admitted to the hospital and given intravenous dihydroergotamine for 2 days. This resulted in pain relief. He was placed on 100 mg of imipramine at night, 40 mg of propranolol twice a day, and 250 mg of valproate sodium three times a day; he was given dihydroergotamine nasal spray for breakthrough headaches. This regimen relieved the headaches somewhat, but the response was not dramatic. He felt better but continued to have bouts of headache with tearing of the eye and nose.

image

Figure 1.—. The MR angiogram at initial presentation was normal.

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Two months later, he noticed an abrupt change in his condition. The severity of pain behind his left eye dramatically increased and was accompanied by a sense of pressure behind the left eye with continual jabbing or throbbing characteristics. This pain kept him awake at night and gave him the urge to move about in attempt to relieve the pain. Pain medication was minimally successful.

On examination, slight ptosis of the left eye was noted for the first time. Because of the rapid and dramatic acceleration of the localized left retroorbital headache, MR imaging and MR angiography were repeated and revealed a large thrombosed left posterior communicating artery aneurysm, which was confirmed by angiography (Figure 2).

imageimage

Figure 2.—. Cerebral angiogram demonstrated an irregular and posteriorly projecting aneurysm from the posterior communicating artery—left, lateral view; right, oblique view.

Following successful obliterative surgery, he was able to return to work. His headaches are now infrequent and resemble mild-pressure tension headaches.

COMMENTS

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES

In this instance, with the throbbing or jabbing pain behind the eye, tearing of the eye, nasal discharge, and the patient's urge to move about restlessly, the headache could easily be termed a cluster headache. The occurrence of headache at night waking him from sleep was also suggestive of cluster headache. What was not present was any circadian sequence to the events. Also, the occurrence of the headache was suddenly interrupted by a dramatic increase in pain and left eye ptosis. This strongly suggested a structural lesion with possible minimal third nerve involvement.

Cluster headache has been previously associated with the presence of arteriovenous malformations 1,2 and vertebral artery aneurysms. 3 In this patient, cluster headache disappeared after clipping of the vertebral artery aneurysm.

In 1981, Sekhar and Heros listed factors that are important in aneurysmal enlargement. 4 Axial stream impingement, water hammer effects, and arterial wall defects at bifurcations are discussed. Hypertension and smoking were considered significant risk factors. All of these factors could have been operative in our patient.

In 1987, Schubiger et al noted the mechanism of growth in “giant thrombosed” aneurysms. 5 Mentioned are multiple episodes of hemorrhage into an enlarging clot, according to the “slow growth by multiple small hemorrhages principle.” They concluded that an aneurysmal wall can also behave like the membrane of a chronic subdural hematoma causing changes in size. In his monograph on the cluster headache syndrome, Sjaastad emphasized carotid artery involvement as one of the major mechanisms in cluster headache. 6 Our patient could have had a small aneurysm not demonstrated on MR angiography that changed blood flow through the artery, thus affecting the nerve endings of the ophthalmic division of the trigeminal nerve resulting in altered trigeminal vascular responses. This could also activate autonomic innervation allowing for tearing and redness of the eye.

The demonstration of many of the characteristics of cluster headache in our patient provided an unusual opportunity to note dramatic changes in headache characteristics as an indicator of rapid aneurysmal enlargement and thrombosis. The immediate availability of imaging and surgery was probably a lifesaving use of modern technology. This case illustrates the importance of alertness in obtaining repeat imaging, which should be emphasized particularly in this environment of cost awareness and containment. It is also a reminder that cluster headache can accompany skull base lesions involving the carotid artery.

REFERENCES

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES
  • 1
    Mani S & Deeter J. Arteriovenous malformation of the brain presenting as a cluster headache—a case report. Headache. 1982;22:184-185.
  • 2
    Herzeberg L, Lenman JA, Victoratos G, Fletcher F. Cluster headaches associated with vascular malformations. J Neurol Neurosurg Psychiatry. 1975;38:648-649.
  • 3
    West P & Todman D. Chronic cluster headache associated with a vertebral artery aneurysm. Headache. 1991;31:210-212.
  • 4
    Sekhar LN & Heros RC. Origin, growth, and rupture of saccular aneurysms: a review. Neurosurgery. 1981;8:248-260.
  • 5
    Schubiger O, Valavanis A, Wichmann W. Growth-mechanism of giant intracranial aneurysms; demonstration by CT and MR imaging. Neuroradiology. 1987;29:266-271.
  • 6
    Sjaastad O. Cluster Headache Syndrome. Philadelphia: WB Saunders; 1992:109-113.