Cluster headaches are also known as migrainous neuralgia, histamine headache, rock neuralgia, pteropalatine neuralgia, and Horton headache. It is a series of severe headaches that occur suddenly over a period of time, usually without aura. The pain is usually located in the orbit or frontotemporal region of one eye, and may be accompanied by ipsilateral conjunctival congestion, lacrimation, eyelid edema, nasal congestion, or runny nose, and sometimes pupil narrowing, drooping lids, flushing, and cheek swelling. The headache is mostly non-pulsating and severe, and the patient is restless or shaking from front to back, and some patients punch their heads to relieve the pain. Many patients have headaches at regular intervals, with each attack lasting 15 to 180 minutes, and then resolving on their own. The attacks last from 2 weeks to 3 months in a row (called cluster), and many patients have cluster attacks that occur in the same season of the year. Intermittent periods last from a few months to a few years, during which the symptoms resolve completely. About 10% of patients have chronic symptoms. The disease is most common in young people (20-40 years old), 4-7 times more often in men than in women, and there is generally no family history. When the headache attack with analgesics and tranquilizers is not effective, you can apply oxygen inhalation (with a mask, 10 l/min, not less than 15 minutes) or intranasal drops of 2% lidocaine. Also can be used to inject 6mg subcutaneously. To prevent and shorten the clustering period, corticosteroids, lithium carbonate, ergotamine or calcium channel blockers can be used. Prednisone (start with 40-60mg/d and reduce the dose after 10 days) is more effective and can shorten or stop the cluster phase. In chronic cases, lithium carbonate (600mg/d) can be used. Horton’s believes that this type of headache is closely related to histamine, and it has been shown that 60% of patients with this disease can induce headache attacks by subcutaneous injection of histamine during intermittent periods, and the increase and decrease of histamine in blood are very rapid, suggesting that it is related to acute headache attacks. Clinical manifestations The headache of this disease is characterized by a series of headache attacks that appear to come in clusters. The attacks are periodic and have no antecedent symptoms. The pain starts around the eye sockets on one side and extends rapidly to the frontal-temporal region, and in severe cases may involve the opposite side. The pain is pulsating, with drilling or burning pain, and can be awakened during sleep. The characteristic concomitant symptoms include facial flushing, sweating, tearing on the affected side, conjunctival congestion, and nasal congestion. In addition to superficial temporal artery anger, there is also incomplete Horner’s syndrome such as narrowing of the affected pupil and drooping eyelids. The attacks can occur one to two times a day, with each attack lasting about tens of minutes to two to three hours, and disappear quickly with a long remission time. Patients rarely experience posterior fatigue or drowsiness, and the headache occurs regularly at approximately the same time each day, often in the late afternoon or early morning. Headache attacks can be triggered by alcohol or nitroglycerin consumption. The headache is often confined to the same side. Differential diagnosis (a) Migraine headache begins as a dull pain in the supraorbital, retroorbital or frontotemporal area of one side, which grows in intensity with a throbbing nature and then continues as a severe fixed pain and extends to the whole half of the head or even the upper neck. The patient is pale, often with nausea and vomiting, and the headache usually lasts all day and is often terminated by sleep. The headache is often preceded by prodromal symptoms and is mostly bilateral, usually with onset in adolescence and most often with a family history. There is a slight increase in histamine and a significant decrease in pentazocine (5-HT) in the blood. (Sluder’s craniofacial vascular pain occurs mostly in males and presents with unilateral fixed paroxysmal headache involving the orbit and its upper and lower regions without transcending to the opposite side, accompanied by vegetative and vascular-secretory symptoms such as Horner’s sign, conjunctival congestion, lacrimation, nasal blockage and unilateral runny nose. There are no cortical symptoms. Development is idiosyncratic, with daily or daily episodes for 3 to 6 weeks, followed by complete remission for days or years, and then recurrence. (iii) Basilar migraine is common in young women and is closely related to menstruation. The onset of migraine is sudden and the prodromal symptoms include visual aura: flashing light, glowing dark spots, hemianopia or transient blackness. There may be vestibular dysfunction, hearing loss, and cerebellar symptoms such as vertigo, tinnitus, ataxia, and dysarthria. The aura lasts for a few minutes to half an hour and then a severe occipital pain, often throbbing, is present, often accompanied by vegetative symptoms such as nausea and vomiting. In some cases, transient impairment of consciousness may occur. This type of headache is a diffuse vasomotor disorder. Treatment The effect of analgesic and tranquilizing drugs is not good when headache is attacked; oxygen (100% oxygen 8~10L/mim, 10~15min); sumatriptan or dihydroergotamine can rapidly relieve headache; prednisone 40~60mg/d orally for 1 week typically shows dramatic improvement of pain can be relieved within a few hours and can be gradually reduced and stopped within 2d in the second week. Relapse prevention during seizures: mexigargin 2~8mg orally, 1 time/d; calcium antagonist (isobodine extended release type). Prevention of nocturnal seizures: rectal suppository of ergotamine & subcutaneous injection of dihydroergotamine at bedtime.