Algies vasculaires de la face (cluster headaches)

The clinical presentation of vascular facial pain is a stereotypic diagnosis which generally does not correspond to one specific problem: the patient complains of excruciating pain in a hemiface which develops in a few minutes and predominates in the peri and retroorbital region. This pain may last one or two hours and resolve in a few minutes. The presentation is even more typical when associated with other signs: ptosis, myosis (Horner's syndrome), tears, rhinorrhea or nasal congestion. Crises may be repeated every day for one or two months, generally at a given time in the day, and often at night. Cluster headaches occur once or twice a year and are episodic. Treatment is basically oxygen therapy, mainly with Sumatriptan (Imiject 6 mg sc). Prophylaxis for severe cases may require emergency corticosteroid therapy which can be continued several days (60 mg prednisone/jay for 8-10 days). To follow-up steroid therapy, or in combination in specific cases, many propose a two month regimen using verapamil, methysergide++, lithium, or antiepileptics. Chronic forms are much more difficult to treat and almost always require combination therapy. Most therapeutic failures result from under dosing. A more aggressive technique, stimulation of the posteroinferior hypothalamus, should be mentioned, but has not yet achieved proven efficacy.