Alcohol and Cluster Headaches

CASE HISTORY This 50-year-old white man has a 5-year history of headaches described as an 8/10 in intensity stabbing in the left temple and sometimes around the left ear associated with tearing and redness of the left eye, congestion of the left nares, and light and noise sensitivity but no aura. During a headache, he prefers to sit or lie down. Without treatment, the headache lasts about 2 hours. Since the onset, the headache has been triggered almost all of the time by alcoholic beverages with the onset 30-45 minutes later. Perhaps one time per year the headache occurs spontaneously. The headaches have been triggered by drinking white or red wine, margaritas, beer, vodka, and grappa. Every evening, he usually drinks 3 margaritas and 2 glasses of Chardonnay and occasionally other alcoholic beverages. He does not drink at other times of the day. About twice a month, he has 6 or more drinks. He scores a 16 on the Alcohol Use Disorders Identification Test (AUDIT). (A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption in adult populations.) The headaches are invariably triggered by lesser and greater amounts of alcohol intake. The headache goes away in about 30 minutes if he takes zolmitriptan 5 mg nasal spray or tablet or rizatriptan 10 mg at the onset. A few weeks after starting a triptan, he noticed that if he takes any of these triptans 5 minutes before his first drink, he only gets a headache about once a month. He has been taking one of these triptans on a daily basis for 3.5 years. If he does not take the triptan preemptively before drinking, he will get a headache. One hundred percent oxygen at 12 liters per minute was not effective. Topirimate was not effective for prevention. He was prescribed verapamil on a number of occasions but did not start the medication. Despite multiple recommendations, he did not seek counseling for alcohol abuse. The unknown risk of daily triptan use was discussed with the patient several times. Past medical history was otherwise negative. He smokes one pack per day. He has a white-collar job working in sales. Neurological examination is normal. Questions.—How common and what are the triggers in cluster headache? To be considered a trigger, how long after exposure to the trigger should the headache begin? How often is alcohol a trigger and what types? Will greater amounts of alcohol trigger a Case history submitted by: Randolph W. Evans, MD, 1200 Binz no. 1370, Houston, TX 77004, USA.