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Posted by Don M. ( on August 19, 2000 at 08:07:25:

Friday August 18 5:38 PM ET
Headaches may not always involve pain

By Penny Stern, MD

NEW YORK (Reuters Health) - When is a headache not a head ache? Apparently, pain may not always characterize at least one type of headache.

Dr. Rolf Salvesen of the University of Troms in Norway, describes an unusual case of apparent pain-free cluster headache in a young man in the August 8th issue of Neurology.

``To my knowledge, this is the first published case of a patient with all the typical hallmarks of (cluster headache) except pain,'' Salvesen writes.

According to Salvesen, the 22-year-old patient first came to medical attention complaining of a drooping left eyelid and a contracted left pupil, as well as left-sided nasal stuffiness--all classic symptoms of cluster headache.

But as Salvesen explained to Reuters Health, ``patients with cluster headaches suffer from attacks of intense pain situated in and around one eye and sometimes in one entire side of the head.'' This patient, however, reported no pain.

The episodes were ``frequent,'' the patient said, ``one to three attacks every day for a period of a few weeks, each attack lasting between 1 and 2 hours,'' Salvesen writes.

The physicians called onto the case actually witnessed two attacks that included the symptoms recounted by the patient as well as several other features: a reddened left eye and a lack of sweating on the left side of the forehead.

Imaging studies were performed but a specific source for the odd symptomatology eluded detection and the episodes eventually ceased.

Flash forward 6 years and the same patient reappears with many of the original symptoms and one important addition: he now was experiencing pain around the left eye.

When administered sumatriptan, a drug commonly used to treat migraine headaches, the pain was ``alleviated...within 30 minutes,'' Salvesen said.

The physical examination and a computed tomography scan were, once again, not especially helpful. But, ``after 6 weeks, the attacks of pain subsided, as did his (drooping eyelid). Six months later, a slight left-sided (contraction of the pupil) was the only abnormal finding,'' according to the report.

It has long been accepted, Salvesen said, ``that the symptoms mentioned are a reflex reaction to the pain mediated through specific (neural) pathways. This view has been dominating the research field during...recent years.''

Yet in this case, the evidence points to what was ``an extraordinary initial presentation'' of cluster headache, the researcher explained. ``It gives evidence that the characteristic symptoms of the syndrome...must have a primary reason and cannot be a mere reflex reaction to the pain.''

Salvesen suggests that there may be many more patients with similar symptoms ``where both the patients and the doctors will be worried that the symptoms are due to more alarming reasons, causing intensive investigation over time.'' Awareness of this case may help eliminate some of the anxiety associated with these symptoms.

Salvesen believes that the symptoms of cluster headache may ''be due to a primary dysfunction of the important structure within the brain. Probably the key to solving the riddle of cluster headache will be found within the hypothalamus.''

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