J Neurol Neurosurg Psychiatry 2001;70:613–617 613 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.70.5.613 on 1 May 2001. Downloaded from Cluster headache in women: clinical characteristics and comparison with cluster headache in men T D Rozen, R M Niknam, A L Shechter, W B Young, S D Silberstein Abstract always been identified as a disorder of men, Objective—To study the clinical charac- with a male to female ratio of 6–7:1.1 Most of teristics of cluster headache in women. the accepted clinical characteristics of cluster Cluster headache is a disorder of men headache have been established through obser- (male to female ratio 6–7:1). vation of men with this disorder. Very few Methods—Retrospective chart review to studies have been dedicated to describing the identify all women diagnosed with cluster disorder in women because of its rarity. headache at an academic headache centre Manzoni1 has suggested that the sex ratio for from January 1995 through July 1998. cluster headache is decreasing and that more Results—Thirty two women and 69 men women are developing or being diagnosed with were identified. The mean age of onset of cluster headache. We attempted to better cluster headache was 29.4 years in women define the clinical characteristics of cluster versus 31.3 years in men. Two peaks of headache in women and compare and contrast onset in women (2nd and 5th decade) were these manifestations with those in men. identified compared with one in men (3rd decade). Episodic cluster headache was present in 75% of women and 77% of men. Women and men had on average 3 attacks Patients and methods a day, but attack duration was shorter in We carried out a retrospective chart review at women (67.2 minutes v 88.2 minutes). the JeVerson Headache Center (a university Cluster headache period duration (11.1 based academic headache clinic) to identify all weeks v 10 weeks) and remission periods women diagnosed with cluster headache from (21.1 months v 23.1 months) were similar January 1995 to the end of July 1998. Each in women and men. Miosis and ptosis patient had to satisfy the International Head- seemed to be less common in women ache Society (IHS) criteria for cluster head- (miosis 13.3% v 24.6%, ptosis 41.9% v ache2: at least five attacks of severe unilateral, 58.1%) whereas lacrimation and nasal orbital, supraorbital, and/or temporal pain that congestion/rhinorrhoea were almost last from 15 to 180 minutes untreated. The equally prevalent in women and men. headache needed to be associated with at least http://jnnp.bmj.com/ Women had more nausea than men (62.5% one of the following signs or symptoms: v 43.5%, p=0.09) and significantly more lacrimation, conjunctival injection, rhinorrhea, vomiting (46.9% v 17.4%, p=0.003). Photo- nasal congestion, forehead and facial sweating, phobia occurred in 75% of women and miosis, ptosis, or eyelid oedema. A total of 32 81.2% of men, and phonophobia occurred women were identified. A sample of 69 male in 50% of women and 47.8% of men. patients with cluster headache, who were diag- Conclusions—The clinical characteristics nosed during the same time period, was of cluster headache in women are very obtained for clinical comparison. These male on September 29, 2021 by guest. Protected copyright. similar to those in men. Women develop Department of patients represented the most recent seen with Neurology, JeVerson the disorder at an earlier age of onset and cluster headache at the JeVerson Headache Headache Center, experience more “migrainous symptoms” Center and did not represent the entire male Thomas University with cluster headache, especially vomit- cohort diagnosed during the study period. All Hospital, 111 South ing. Both men and women have frequent of the patients included in the study were diag- 11th Street, Gibbon photophobia and phonophobia with clus- nosed by a neurologist with expertise in head- Building, Suite 8130, ter headache attacks. These symptoms are Philadelphia, ache. Using a uniform questionnaire, we evalu- Pennsylvania 19107, not included in the International Head- ated patient demographics (age of onset of USA ache Society cluster headache criteria, cluster headache, race, cluster headache type), T D Rozen suggesting the need for possible criteria cluster headache attack characteristics (fre- R M Niknam revision. quency, duration), and associated symptoms. A L Shechter (J Neurol Neurosurg Psychiatry 2001;70:613–617) W B Young The IHS criteria symptoms for cluster head- S D Silberstein Keywords: cluster headache; women; sex; autonomic ache were collected, as well as so called symptoms “migrainous symptoms,” including nausea, Correspondence to: vomiting, photophobia, and phonophobia, Dr T D Rozen [email protected] which in the past were not thought to be typi- Cluster headache is a stereotypic headache dis- cal of cluster headache and are not part of the Received 26 April 2000 and order characterised by short lasting attacks of IHS criteria. If the chart was not complete, in revised form 23 November 2000 severe unilateral head pain with associated patients were contacted by telephone to obtain Accepted 11 January 2001 autonomic symptoms. Cluster headache has the missing data. www.jnnp.com 614 Rozen, Niknam, Shechter, et al J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.70.5.613 on 1 May 2001. Downloaded from Table 1 Cluster study: demographics significantly more vomiting (46.9% v 17.4%, p=0.003). Photophobia occurred in 75% of Women Men p Value women and 81.2% of men, and phonophobia Age of onset (y) (mean (SD)) 29.4 (15.9) 31.3 (13.5) 0.542 occurred in 50% of women and 47.8% of men Race (%): (table 3). Six women and six men had a White 75.0 82.6 0.372 Black 25.0 17.4 personal history of migraine. Type (%): Thirty four per cent of women and 45% of Episodic 75.0 76.8 0.842 men stated that alcohol would induce a cluster Chronic 25.0 23.2 headache, and 100% of women and 91% of men said that sleep was a trigger. A history of STATISTICAL ANALYSIS 2 cigarette smoking was identified in 75% of A ÷ analysis was used for categorical data, and women and 60.8% of men. Cluster headache t testing was used for continuous variables. A p led to disability (either needing to stop an value<0.05 was considered significant. activity or being unable to carry out an activity with typical performance) in 33% of women Results and 25% of men. Thirty two women and 69 men were identified. The mean age of onset of cluster headache was 29.4 years in women versus 31.3 years in men Discussion (table 1). Most women had developed their CLUSTER HEADACHE DEMOGRAPHICS first ever cluster headache by the age of 20, Cluster headache is primarily a disorder of whereas most men developed their first cluster men, and most of its recognised manifestations headache by the age of 25 (fig 1 A and B) have been identified through observation of Women had a peak of onset around the age of male patients. The reason for the male 20; a second peak, noted around the age of 50, predominance is unknown. It may be due to may have been artifactual as it encompassed male sex hormones or specific male behav- only three of 32 patients. Men had one peak of ioural traits. During periods of cluster head- onset in the 3rd decade. ache, there is a lowering of serum testosterone In our series, 75% of women and 82.6% of concentration; this may be a cause or a conse- men were white, whereas more African- quence of the headache, and may be due to American women had cluster headache than hypothalamic involvement.3 Replacement of African-American men (25% v 17.4%) (table testosterone does not lead to improvement in 1). Episodic cluster headache (more than 14 cluster headache, but it does lead to male headache free days a year) was present in 75% hypersexuality.4 Men are more prone to head of women and 76.8% of men. Chronic cluster trauma, which may cause cluster headache. headache occurred in the remainder (25% and Freidman and Mikropoulos5 found a head 23.2% respectively) (table 1). Both women and injury frequency of 16% in their patients. Until men averaged about three attacks a day recently, men have had heightened stressors of (women 3.2, men 3.0), but the duration of each daily living (money maker, physical labourer) individual attack was shorter in women (67.2 compared with women, and this may have pre- minutes) than in men (88.2 minutes) disposed them to developing cluster headache. (p=0.074) (table 2). Cluster headache period Men also consumed more alcoholic beverages http://jnnp.bmj.com/ duration was not significantly diVerent in and smoked more cigarettes than women, and women and men (11.1 weeks v 10 weeks). these social activities have been linked to Average remission times were almost equal in genesis of the disorder. Cluster headache seems women (21.1 months) and men (23.1 months). to be increasing in women, which may be sec- Miosis and ptosis were slightly less common in ondary to women taking on the occupations women than in men (miosis 13.3% v 24.6; pto- and vices of men. sis 41.9% v 58.1%). Lacrimation (women The disorder in women is not exactly the 79.3%, men 83.8%) and nasal congestion/ same as in men. It seems to start earlier in life on September 29, 2021 by guest.