Comment: “The Premonitory Symptoms (Prodrome): A Tertiary Care Study of 893 Migraineurs”

Abstract

The age of onset in cluster headache may vary. However, most of the patients experience the first attacks between 20 and 30 years of age. 1 We have recently described two patients with a very late onset cluster headache. 2 Here, we describe the case of a patient with-to our knowledge-the oldest age of onset of typical cluster headache.An 89-year-old woman presented to the neurological inpatient clinic because of severe headache attacks for 4 months. The attacks occurred about two or three times a day and lasted between 20 and 45 minutes. They were strongly right sided, accompanied by redness and tearing of the right eye. There was a nasal congestion on the right side. The patient was not aware of any trigger factors. She never had attacks like this before in her life, and there was no evidence for dementia. The family history was free of headache disorders. Another neurological hospital suspected trigeminal neuralgia and treated her with gabapentin. This and simple analgesics were without any effect. An MRI scan of the skull was unremarkable as was the neurological examination. The woman was very healthy for her age and did not show any mental disorders. She was treated with sumatriptan (3 mg subcutaneously) that stopped the attacks after about 10 to 15 minutes. A prophylactic treatment with verapamil was started and increased up to 240 mg per day. The diagnosis of cluster headache was made based on a total observation period of 10 days. After starting the prophylactic medication, the woman did not complain of any further attack.The oldest age of onset in cluster headache described in the previous literature was-to the best of our knowledge-71 years 3 and 83 years. 2 Our case shows that the age of onset in cluster headache may be even higher. Therefore, it has to be considered in future epidemiologial and genetic studies that the age of onset in cluster headache may vary widely and that a clinically asymptomatic patient even in higher ages will not necessarily be free of cluster headache for all his life.