70 Headache Medicine, v.2, n.2, p.70-72, Apr./May/Jun. 2011

Why cluster headache is also called "suicide

headache"?

Por que a cefaleia em salvas é também chamada de "cefaleia suicida"?

ABSTRACTABSTRACT

ABSTRACT

Introduction:Introduction:

Introduction: The cluster headache (CH) is characterized

by attacks of excruciating unilateral headache, affecting mainly

the fronto-orbital region associated with autonomic signs like

lacrimation and conjunctival injection, eventually leading the

patient to suicide.

Objective:Objective:

Objective: To report a case in which a

patient committed self-harm during the crises of CH.

CaseCase

Case

report: report:

report: An 85-year-old man was evaluated at the ambulatory

of the Getúlio Vargas Hospital, Pernambuco. The patient was

also subjected to a neurological examination and a cerebral

computed tomography. The patient presented intense pain,

with crises that last around three hours, in the right fronto-

orbital region with spread to the ipsilateral hemicranium. A

relevant fact is that during one of the painful episodes the

patient threw boiling water on the side of the pain, causing a

second-degree burn on part of the head.

Comment: Comment:

Comment: The

pain intensity in some cases may lead the patient to self-harm,

so it is necessary that there be an early specialized approach

with the objective of avoiding severe physical and psychological

damages like the one that was described in this report.

Keywords:Keywords:

Keywords: Cluster headache; Attempted suicide.

RESUMORESUMO

RESUMO

ntrodução:ntrodução:

ntrodução: A cefaléia em salvas (CS) é caracterizada por

crises excruciantes de dor de cabeça unilateral, acometendo

principalmente a região fronto-orbitária, associada a sinais

autonômicos como lacrimejamento e hiperemia conjuntival,

levando muitas vezes o paciente ao suicídio. Objetivo: Relatar

o caso de um paciente que durante a crise de CS cometeu

auto-agressão.

Relato do caso:Relato do caso:

Relato do caso: Avaliou-se um homem de

CASE REPORTCASE REPORT

CASE REPORT

Hugo André de Lima Martins

1,2

, Valdenilson Ribeiro Ribas

, Daniella Araujo Oliveira

, Elder Machado

1,2,

Louana Cassiano da Silva

, Silvya Nery Bernardino

, Marcelo Moraes Valença

Hospital Getúlio Vargas

Departamento de Neuropsiquiatria, Universidade Federal de Pernambuco, Recife, PE

Departamento de Fisioterapia, Universidade Federal de Pernambuco, Recife, PE

Martins HA, Ribas VR, Oliveira DA, Machado E, Silva LC, Bernardino SN, Valença MM.

Why cluster headache is also called "suicide headache"?. Headache Medicine. 2011;2(2):70-72

85 anos de idade no ambulatório de cefaléia do Hospital

Getúlio Vargas, Pernambuco. O paciente também foi sub-

metido a exame neurológico e realização de tomografia

computadorizada cerebral. O paciente apresentava dor

intensa, em crises de três horas de duração, em região fronto-

orbitária direita com irradiação para o hemicrânio ipsila-

teralmente. Fato relevante é que durante um dos episódios

dolorosos o paciente jogou água fervendo na região onde

sentia a dor, ocasionando queimadura de segundo grau em

parte da cabeça.

Comentário: Comentário:

Comentário: A intensidade da dor em

alguns casos pode levar o paciente à auto-agressão, havendo

a necessidade de abordagem especializada precocemente com

o objetivo de evitar danos físicos e psicológicos graves como

descrito neste relato.

alavrasalavras

alavras

chaves:chaves:

chaves: Cefaleia em salvas; Tentativa de suicídio.

INTRODUCTION

The cluster headache (CH) is the most intriguing

headache of any other type known.

1-10

It is characterized

by attacks of intense unilateral pain associated with

autonomic signs like conjunctival injection, lacrimation,

rhinorrhea and nasal congestion.

2,5,6

This disease has

predominance in men and the proportion of gender has

varied between 5:1 and 6.7:1.

Headache Medicine, v.2, n.2, p.70-72, Apr./May/Jun. 2011 71

The pain of the CH occurs typically around the eye

and orbit of the affected side. Each attack lasts on average

45-90 min.

It is the most painful of the primary

headaches, it has been called as "suicide headache"

because sufferers have contemplated suicide in fear of

another cluster attack or have even taken their own lives

during an attack.

Below, we present an excerpt of a

patient report depicting his pain: "They say that feeling

pain is to be alive. In this case, I must be the most alive

person on the Earth. I have been to hell thousands of

times, because I suffer of chronic cluster headache and I

have around 210 crises per month. To me, comparing

other types of headache with the cluster headache is like

comparing a twisted ankle with a compound fracture of

the leg. The difference is that the source of my pain is

hidden and makes the other people indifferent to everything

that happens to me".

Sometime the pain is extremely severe that patients

with CH, in frustration with the pain, attempt to alleviate

their headache by hitting their head on the wall, or press

really hard on the eye. Thus, we describe the case of a

patient that committed self-harm during the painful attack

of CH that he considers unbearable.

CASE REPORT

An 85-year-old man was evaluated at the Getúlio

Vargas Hospital, Recife, Pernambuco, Brazil, with a

history of intense pain, and crisis duration of three

hours, in the right fronto-orbital region radiating to

the ipsilateral hemicranium. The crises were always

accompanied by conjunctival injection and eyelid

semiptosis of the same side. The patient reported that

the pain initiated three weeks before and occurred in

a frequency of three times a day. He also said that he

felt intense agitation during the painful crises; he could

not stand still and had difficulties to initiate and

maintain sleep. A relevant fact is that during one of

the painful episodes the patient threw boiling water

on the side of the pain, causing a second-degree burn

(Figure 1).

The neurological examination was normal in the

intercritical period. A computed tomography scan of the

brain was done and showed a hypodense lesion

compatible with cerebral atrophy in the right inferior

temporal region. There was a contraindication for the

use of verapamil and lithium carbonate, but the patient

started to use chlorpromazine 100 mg at night with an

excellent clinical response.

COMMENTS

The reported case presents the typical characteristics

of the CH, although the beginning of the crises in the

ninth decade of life is not common, as well as the

unspecific alteration observed in the image exam that

brings the possibility of a secondary cause to justify the

pain. During the crises, the patient stayed in a state of

agitation and moved constantly. He reported that the

pain worsened when resting, what it was described in

other studies.

Other authors reported that the cluster

patients are restless and occasionally even violent during

an attack. Patients with CH have destructive behavior

that may even result in injuries; some may commit suicide

during an attack.

The intensity of pain in some cases

may lead the patient to self-harm, so it is necessary an

early specialized approach with the objective of avoiding

serious physical and psychological damages, as it is

described in this report. The medical treatment of CH

includes acute, transitional, and maintenance

prophylaxis.

Although the mainstay of prophylactic

therapy is verapamil,

in this present study, the patient

had an excellent therapeutic response using

chlorpromazine, which was already successfully used by

other authors for more than thirty years.

Recently, other

authors used olanzapine, an atypical antipsychotic, in

CH crises.

This drug relieves the pain quickly and had a

consistent response after multiple attacks.

Validated

treatment options are limited

7,9

and it is necessary to look

for other options that may contemplate all the involved

peculiarities in the clinical condition of each patient. The

evaluated patient presented besides the excruciating

pain, tendency to suicide, sleep disorder and

Figure 1. Arrow showing a second-degree burn on the frontal region

caused by boiling water.

WHY CLUSTER HEADACHE IS ALSO CALLED "SUICIDE HEADACHE"?

72 Headache Medicine, v.2, n.2, p.70-72, Apr./May/Jun. 2011

contraindications for drug use of first line in his medical

treatment, what lead us to attempt the use of a drug of

low cost that fit perfectly in his disease profile reaching

an excellent therapeutic response.

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Corresponding author

DrDr

. Hugo André Lima Martins. Hugo André Lima Martins

. Hugo André Lima Martins

Rua Josefa Miranda de Farias, 33 – Centro

55750-000 – Surubim-PE

hugomt2001@yahoo.com.br

MARTINS HA, RIBAS VR, OLIVEIRA DA, MACHADO E, SILVA LC, BERNARDINO SN, ET AL