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   Table of Contents      
CASE REPORT
Year : 1991  |  Volume : 39  |  Issue : 4  |  Page : 181-182

Cluster headache or narrow angle glaucoma?


1 O.E.U. Institute of Ophthalmology, Kasturba Medical College, Manipal, India
2 Department of Neurosciences, Kasturba Medical College, Manipal, India

Correspondence Address:
Palimar Prasad
O.E.U. Institute of Ophthalmology, Kasturba Medical College, Manipal-576 119
India
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Source of Support: None, Conflict of Interest: None


PMID: 1810883

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  Abstract 

A 47 year old man with episodes of attacks of pain, redness and mild blurring of vision was investigated for narrow angle glaucoma in view of shallow anterior chambers and a cupped optic disc. The history was reviewed following a spontaneous attack in hospital, which had features other than acute glaucoma. A diagnosis of cluster headache was made on the basis of tests. Cluster headache has been defined as unilateral intense pain, involving the eye and head on one side, usually associated with flushing, nasal congestion and lacrimation; the attacks recurring one or more times daily and lasting 20 - 120 minutes. Such attacks commonly continue for weeks or months and are separated by an asymptomatic period of months to years. This episodic nature, together with unilaterality and tendency to occur at night, closely mimics narrow angle glaucoma. Further, if patients have shallow anterior chambers and disc cupping, the differentiation becomes more difficult yet critical. Resource to provocative tests is often the only answer as the following case report demonstrates.


How to cite this article:
Prasad P, Subramanya R, Upadhyaya N S. Cluster headache or narrow angle glaucoma?. Indian J Ophthalmol 1991;39:181-2

How to cite this URL:
Prasad P, Subramanya R, Upadhyaya N S. Cluster headache or narrow angle glaucoma?. Indian J Ophthalmol [serial online] 1991 [cited 2019 May 21];39:181-2. Available from: http://www.ijo.in/text.asp?1991/39/4/181/24426


  Case report Top


Mr. K, 47 years old, was seen at a peripheral clinic with history of attacks of severe pain in and around the left eye, associated with watering, redness and some diminution of vision. These attacks had begun 5 years ago occurring in spells over a few months with symptom-free intervals in between. There had been a 2 year quiescent period. The attacks occurred only in the left eye, at night, interfering with his shifts as a loader. On examination, the visual acuity was 6/6 in each eye and the anterior chambers were shallow. The right optic disc was cupped with cup-disc (C:D) ratio of 0.6 and a healthy neuroretinal rim; the left disc had a C:D of 0.3. He was referred for admission and investigations to rule out narrow angle glaucoma.

On admission, intra-ocular pressures (IOP) were 12mm Hg in both eyes and gonioscopy revealed open angles all around. Visual fields, tonography and diurnal curves were normal. On closer ques­tioning, he did say that these attacks were preceded by a feeling of warmth and nasal stuffiness and associated with lacrimation; haloes had never been experienced. A variant of migraine was suspected.

On the second night following admission, an attack occurred spontaneously. He was restless and begun to pace about. The left eye was affected. The IOP were 12mm Hg in the right eye and 16 mm Hg in the left. The left upper lid was mildly ptosed and the pupil smaller. A revised diagnosis of cluster attacks was made and neurological consultation sought. Two attacks were precipitated with informed consent as follows: sublingual nitroglycerin 2 mg was administered. Beginning 35 minutes later, the patient noted a feeling of warmth over the left half of the face which led on to intense pain, conjunctival congestion and lacrimation. There was mild ptosis and miosis. The attack was relieved by inhalation of 100% oxygen (8-10 litres/min) for 10 minutes. He was totally free of symptoms 30 minutes later. In­domethacin tablets (sustained release) 75 mg o.d. were started. The second attack was precipitated to note the relieving effect of ergotamine tablets (which could be carried to his workplace). The attack was less severe [Figure - 1][Figure - 2] and easily aborted. At review, a month later, he had not suffered any further attacks.


  Discussion Top


When patients are seen with a suspicion of narrow angle glaucoma, it is mandatory to carry out further evaluation. This patient had shallow anterior chambers together with cupping of the optic disc, although on the side contralateral to his symptoms. Gonioscopy ruled out a narrow angle element. Also, the diurnal curve and tonography were normal. This led us to review his history. Before provocative tests for angle closure glaucoma could be instituted an attack oc­curred spontaneously.

Cluster attacks resemble narrow angle glaucoma in being episodic, unilateral, often nocturnal and as­sociated with nausea and vomiting. A congested eye may be frequently accompanied by an increased IOP (though moderate), during the attack [2] further complicating matters. This phenomenon occurred on all occasions in our patient. How, then, does one differentiate the two disorders? Cluster headaches occur in males (5:1) [1] who are said to have a particularly masculine physique [2]. Lacrimation is an important feature (87%) [4]. The patient is restless and paces about in agony as opposed to patients during acute attacks of narrow angle glaucoma. If the physician is fortunate enough to be present during the attack, miosis and ptosis are notable features.

As a last resort provocative tests must be carried out.

The pathogenesis of this condition is not exactly known, but it may be related to histamine whose serum levels are raised in the acute phase. This is the basis of the histamine provocative test [5]. Nitroglycerin sublingually precipitates an attack which is supported to be identical to the spontaneous one [6]. Plasma serotonin values are also found to be raised (decreased in migraine).

The treatment of cluster headache is prophylactic in the form of ergotamine, prednisolone, methysergide, lithium or indomethacin [7],[8]. An attack can best be aborted by inhalation of oxygen [9]. Ischemic optic neuropathy is known to occur in migraine and may explain the asymmetrical cupped disc in the face of negative glaucoma investigations.

This case illustrates how closely narrow angle glaucoma may be mimicked by cluster headaches. The patient can be spared an unnecessary laser iridotomy/surgical iridectomy and a label of glaucoma by differentiating one from the other.

 
  References Top

1.
Troost B T. Migraine in T D Duan(Ed), Clinical Ophthalmology, Chapter 19 pp 13-15. J B Lippincott & Co.. Philadelphia 1988.  Back to cited text no. 1
    
2.
Horven I. Sjaastad 0. Cluster headache syndrome and migraine: ophthalmological support for a two entity theory. Acta Ophthalmol 1977, 55:35-51  Back to cited text no. 2
    
3.
Sjaastad 0. Cluster headache in F C Rose (Ed), Handbook of Clinical Neurology. Vol 4 (48) 1217-246 Elsevier Scientific Publishers, B.V. 1986  Back to cited text no. 3
    
4.
Horton BT. Maclean AR, Craig WM. A new syndrome of vascular headache. Results of treatment with histamine. Preliminary report. Proceedings of the staff meeting of the Mayo clinic 1939; 14:257-260  Back to cited text no. 4
    
5.
Horton BT Histaminic cephalgia: differential diagnosis and treatment. Proceedings of staff meetings of the Mayo clinic 1956: 31:325-333  Back to cited text no. 5
    
6.
Peters GA. Migraine: diagnosis and treatment with emphasis on the migraine tension headache, provocative tests and the use of rectal suppositories 1953: 28: 673-686.  Back to cited text no. 6
    
7.
Lance JW. Headache Ann Neurol 1981: 10:1-10.  Back to cited text no. 7
    
8.
Kudrow L. Comparative study of prednisolone, methysergide and lithium therapy in cluster headache, in Gree R(Ed): Current concepts in migraine research. pp159-163, Raven press, New York, 1978.  Back to cited text no. 8
    
9.
Krinkle EC. Pfeiffer JB. Wilhoit WS. Hamrick LW. Recurrent brief headache in cluster pattern. Trans Ann Neurol Assoc 1952: 77:240-243  Back to cited text no. 9
    


    Figures

  [Figure - 1], [Figure - 2]



 

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