CASE REPORT

Why cluster headache is also called "suicide headache"?

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

Hugo André de Lima Martins1,2, Valdenilson Ribeiro Ribas2, Daniella Araujo Oliveira1, Elder Machado1,2, Louana Cassiano da Silva2, Silvya Nery Bernardino2, Marcelo Moraes Valença2

1Hospital Getúlio Vargas 2Departamento de Neuropsiquiatria, Universidade Federal de Pernambuco, Recife, PE 3Departamento 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

ABSTRACT

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: To report a case in which a patient committed self-harm during the crises of CH. Case 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 frontoorbital 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: 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: Cluster headache; Attempted suicide.

R E S U M O

Introdução: 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: Avaliou-se um homem de

85 anos de idade no ambulatório de cefaléia do Hospital Getúlio Vargas, Pernambuco. O paciente também foi submetido a exame neurológico e realização de tomografia computadorizada cerebral. O paciente apresentava dor intensa, em crises de três horas de duração, em região frontoorbitária direita com irradiação para o hemicrânio ipsilateralmente. 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: 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.

Palavras-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.

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WHY CLUSTER HEADACHE IS ALSO CALLED "SUICIDE HEADACHE"?

The pain of the CH occurs typically around the eye and orbit of the affected side. Each attack lasts on average 45-90 min.10 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.10 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".3

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.

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Figure 1. Arrow showing a second-degree burn on the frontal region caused by boiling water.

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.4 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.10 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.8 Although the mainstay of prophylactic therapy is verapamil,8 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.1 Recently, other authors used olanzapine, an atypical antipsychotic, in CH crises.4 This drug relieves the pain quickly and had a consistent response after multiple attacks.4 Validated treatment options are limited7,9 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

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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.

REFERENCES

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2.Gobel H, Linder V, Heinze A, Ribbat M, Deuschl G. Acute therapy for cluster headache with sumatriptan: findings of a one-year long-term study. Neurology.1998; 51(3):908-11.

3.Vaughan R. My own private purgatory: how cluster headaches affect my life. Headache. 2008. 48(10):1541-3.

4.Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-16.

5.Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology. 2010; 75 (5):463-73.

6.Grosberg BM, Vollbracht S, Robbins MS, Lipton RB. Cluster headache associated with a sixth nerve palsy: a case report. Cephalalgia. 2011;31(1):122-5.

7.Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database Syst Rer. 2010;14(4):CD008042.

8.Halker R, Vargas B, Dodick DW. Cluster headache: diagnosis and treatment. Semin Neurol. 2010; 30(2):175-85.

9.Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomixed trial. JAMA. 2009; 302(22): 2451-7.

10.Dodick DW, Rozen TD, Goadsby PJ, Silberstein SD. Cluster headache. Cephalalgia. 2000;20(9):787-803.

Corresponding author

Dr. Hugo André Lima Martins Rua Josefa Miranda de Farias, 33 Centro 55750-000 Surubim-PE hugomt2001@yahoo.com.br

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