Clusterlike Headache as First Manifestation of a Prolactinoma

Abstract

We report a case of cluster headache in a patient with a macroprolactinoma. Symptomatic cluster headache was suspected because of an unsatisfactory response to medications that are usually effective in idiopathic cluster headache. The neurological examination was normal. However, magnetic resonance imaging demonstrated a large pituitary tumor. One year after starting treatment with cabergoline, the patient remains asymptomatic. Symptomatic cluster headache should be suspected when the clinical features of the headache are atypical. By inducing vascular mechanisms, the parasellar lesion may have played a role in initiating the cluster headache.Key words: cluster headache, pituitary adenoma, macroprolactinoma Abbreviation: CH cluster headache ( Headache 2001;41:723-725) Cluster headache (CH) is a disease with a typical periodic pain pattern. The diagnostic criteria are based on clinical features and the temporal pattern. In primary CH, neuroradiological investigations should not demonstrate any pathological or morphological lesion in the central or peripheral nervous system. Like other vascular headaches, CH is presumed to develop from pathophysiological events, which ultimately activate the trigeminovascular system. 1 Several reports have described the association of clusterlike headache with structural neurological disturbances (Table). [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] We report the occurrence of clusterlike headache in a patient with a pituitary adenoma. The neurological examination was normal, but both neuroradiological and endocrine investigations revealed the presence of a pituitary prolactinoma. CASE HISTORYA 30-year-old man presented with complaints of recurrent headache of 2 years' duration. The pain was severe, sharp, and invariably in the left eye and periorbital region, and usually lasted less than 120 minutes. The attacks were associated with ipsilateral lacrimation, rhinorrhea, injection of conjunctiva, ptosis, and miosis. The pain was never associated with nausea or vomiting and did not increase with Valsalva maneuver. The pain never awakened the patient. Initially, the attacks occurred sporadically, once a day for a period of 20 days, and then he was asymptomatic for a couple of months. The frequency increased in the previous 6 months to three or more episodes per day without any temporal pattern. Because analgesic treatment was not effective and the clinical characteristics had changed, he decided to consult a specialist. The initial neurological examination was normal. There were no signs of cranial nerve involvement. The patient was started on verapamil and given zolmitriptan for pain crises. A cranial computed tomography scan showed a parasellar and suprasellar tumor with left extension into the cavernous sinus. Magnetic resonance imaging (MRI) again demonstrated a left-sided adenoma with cavernous sinus invasion (Figure). His prolactin level was 4759 ng/mL,

The Association between Calcitonin Gene-Related Peptide (CGRP), Substance P and Headache in Pituitary Tumours

“…In addition, migraine attacks must have at least one of: nausea or vomiting, or photophobia and phonophobia [33]. A range of other headache phenotypes have been described in association with pituitary adenomas, including cluster headache [41][42][43], hemicrania continua [44] and SUNCT [11,44,45], which was observed in one case in this study. This suggests that pituitary tumour-associated headache is a heterogenous rather than a homogenous clinical entity and requires high numbers to comment on the relative prevalence of each phenotype, and the association with particular tumour sub-groups.…”

A case of a GH–producing pituitary adenoma associated with a unilateral headache with autonomic signs

“…Hannerz [12] hypothesised that the adenoma induced an impairment of venous flow in the carotid sinus and/or of the superior ophthalmic vein with subsequent vasculitis of the orbital sinus. These events caused stimulation of the first or second trigeminal branches and activation of the trigeminovascular system [12][13][14][15]. Other authors hypothesised, instead, that the adenoma pulled on the bony sellar septum and excited the meningeal arteries and trigeminal fibres located there [4,16].…”

Cluster-like headache: literature review

“…Observations of pituitary adenomas, parasellar meningiomas or neurinomas support the hypothesis that pain and autonomic symptoms in CH originate within the cavernous sinus region [3,7,10]. For some authors, one of the clues for a causal relationship between the two diseases lies in the relief of CLH symptoms without recurrence after treatment of the lesion [13,14,26]. Among arguments to explain such a relationship, Hannertz clearly demonstrated by orbital phlebography that venous drainage in the cavernous sinus was impaired by the tumor.…”

“…Thus, CLH only includes cases that fully adhere to the IHS description of CH differing only by the presence of another disease which may be involved. Greve and Mai [13] or Porta-Etessam et al [14] described such observations in which the occurrence of another neurological disease eliminates the diagnosis of CH even if all the symptoms adhere to IHS criteria. In these cases, several questions remain unanswered.…”

“…In fact, in most cases, duration of pain is actually more prolonged than in CH and autonomic signs are frequently lacking [25]. Nevertheless, Tfelt-Hensen et al [26], Greve and Mai [13] and Porta-Etassam et al [14] described several, well-documented cases. In these observations, pituitary prolactinomas or growth-hormone producing adenomas were always macroadenomas with suprasellar and laterosellar infiltrations.…”