Introduction Cluster headache (CH) is a primary headache characterized by episodes of excruciating pain in the fronto-temporo-orbital area with strict one-sidedness, accompanied by local vegetative signs, lasting 15-180 min. The attacks are concentrated in periods of variable duration that define the active phase and discriminate the episodic from chronic form. The active phases tend to occur in the same patient with a seasonal rhythm and, within the cluster, the crises appear at stable times throughout the day with a circadian trend. Although frequently observed these characteristics have never been formally codified among the diagnostic criteria in the various editions of the International Classification of Headaches (ICHD) proposed by the International Headache Society (IHS). Aims of the study The study has the main purposes to detect seasonal rhythmicity in the appearance of clusters and a regular timing in the onset of attacks within the same active phase. Furthermore, a correlation between CH with the moon phases and the barometric air pressure has been investigated. Material and methods Patients who received a diagnosis of CH according to the ICHD criteria between April 2004 and October 2021 were instructed to promptly contact the Headache Centre on the first day of a new active phase onset and the data were prospectively collected in their clinical sheet. CH was diagnosed in 161 among the 4411 outpatients who referred for a first evaluation: 144 subjects (m: 105, 72.9%; f: 39, 27.1%; ratio m/f: 2.7; average age at CH onset: 37.4±15.3; average age at first evaluation: 46.8±15.0) received the diagnosis of 3.1.1 episodic CH (n=117) and 3.1.2 chronic CH (n=13); 14 presented an isolated active phase and, therefore, a third-level diagnosis was hampered; 17 were excluded because of lack of information (n=13) or modified diagnosis in further controls (n=4). Data concerning the day of appearance of a new active phase, time of onset of the attacks within the cluster and clinical features of the crises were prospectively collected. A total of 550 active phases (average duration 48.0±38.4 days; average intercritical interval was 16.9±28.6 months) was considered. Results A circadian pattern in the onset of the attacks was found in 128 patients (88.9%) with a peak prevalence between 02:00-04:00 p.m. (n=62; 43.1%) (p<0.05) and 02:00-04:00 a.m. (n=57; 39.6%). A seasonal rhythmicity of the appearance of the active phases was found in 71 among the 117 episodic CH sufferers (60.7%), more frequently during the springtime (n=42; 59.1%) (p<0.05) and autumn (n=26; 36.6%). Among them, a stable time of appearance of the attack within the same cluster was found respectively in 68/71 (95.7%) and in 37/46 (80.4%) subjects with predictable and unpredictable seasonality (p<0.05). No significant correlation was found between the beginning of cluster period and lunar phases or average atmospheric pressure. Ipsilateral lacrimation and conjunctival injection were the most frequent autonomic signs which accompanied the attacks (n=101; 70.1%), while miosis, eyelid oedema and sweating were very rare. Conclusion CH is confirmed to present regular biological rhythmicities, both in the seasonal onset of the active phase and in the appearance of the attacks at regular hours within the same cluster. Our results, in line with the literature, allow to propose the circadian patterns as additional tool among the diagnostic criteria of CH in the forthcoming revision of ICHD. No significant correlation has come to light between the beginning of clusters and factors such as lunar phase and barometric pressure.
Introduzione La cefalea a grappolo (CG) è una cefalea primaria caratterizzata da episodi di dolore lancinante nell'area fronto-temporo-orbitale con stretta unilateralità, accompagnati da segni vegetativi locali, della durata di 15-180 min. Gli attacchi si concentrano in periodi di durata variabile che definiscono la fase attiva e discriminano la forma episodica da quella cronica. Le fasi attive tendono a manifestarsi nello stesso paziente con ritmo stagionale e, all'interno del cluster, le crisi si manifestano ad orari stabili nell'arco della giornata con andamento circadiano. Sebbene frequentemente osservate, queste caratteristiche non sono mai state formalmente codificate tra i criteri diagnostici nelle varie edizioni dell'International Classification of Headaches (ICHD) proposta dall'International Headache Society (IHS). Scopo dello studio Lo studio ha le principali finalità di rilevare la ritmicità stagionale nella comparsa dei grappoli e una regolarità circadiana nell'insorgenza degli attacchi all'interno della stessa fase attiva. Inoltre, è stata studiata una correlazione tra CG con le fasi lunari e la pressione atmosferica. Materiale e metodi I pazienti che hanno ricevuto una diagnosi di CG secondo i criteri ICHD tra aprile 2004 e ottobre 2021 sono stati istruiti a contattare tempestivamente il Centro Cefalea il primo giorno di insorgenza di ogni nuova fase attiva e i dati sono stati raccolti prospetticamente nella loro scheda clinica. La CG è stata diagnosticata in 161 dei 4411 pazienti ambulatoriali che si sono rivolti a una prima valutazione: 144 soggetti (m: 105, 72.9%; f: 39, 27.1%; rapporto m/f: 2.7; età media all'esordio della CG: 37.4±15.3; età media alla prima valutazione: 46.8±15.0) ha ricevuto la diagnosi di 3.1.1 CG episodica (n=117) e 3.1.2 CG cronica (n=13); 14 presentava una fase attiva isolata e, quindi, una diagnosi di terzo livello risultava ostacolata; 17 sono stati esclusi per mancanza di informazioni (n=13) o diagnosi modificata in ulteriori controlli (n=4). Sono stati raccolti prospetticamente i dati relativi al giorno di comparsa di una nuova fase attiva, all'ora di insorgenza degli attacchi all'interno del cluster e alle caratteristiche cliniche delle crisi. Sono state considerate 550 fasi attive, con durata media pari a 48.0±38.4 giorni e intervallo intercritico medio 16.9±28.6 mesi. Risultati Un pattern circadiano all'inizio degli attacchi è stato riscontrato in 128 pazienti (88.9%) con un picco di prevalenza tra le 14:00 e le 16:00. (n=62; 43.1%) (p<0.05) e 02:00-04:00 (n=57; 39.6%). Una ritmicità stagionale della comparsa delle fasi attive è stata riscontrata in 71 dei 117 malati di CG episodica (60.7%), più frequentemente durante la primavera (n=42; 59.1%) (p<0.05) e l'autunno (n=26; 36.6%). Un orario stabile di comparsa della crisi nell'ambito del medesimo grappolo è stata riscontrata in 68/71 soggetti con stagionalità prevedibile (95.7%) e in 37/46 (80.4%) con stagionalità non prevedibile (p<0.05). Non è stata trovata alcuna correlazione significativa tra l'inizio del periodo del grappolo e le fasi lunari o la pressione atmosferica media. Lacrimazione omolaterale e iniezione congiuntivale sono stati i segni autonomici più frequenti negli attacchi (n=101; 70.1%), mentre miosi, edema palpebrale e sudorazione sono stati molto rari. Conclusione Si conferma come la CG presenti una ritmicità biologica regolare, sia nell'esordio stagionale della fase attiva che nella comparsa degli attacchi ad orari regolari all'interno dello stesso cluster. I nostri risultati, in linea con la letteratura, consentono di proporre la circadianità oraria e la ricorrenza stagionale come strumento aggiuntivo tra i criteri diagnostici della CG nella prossima revisione della ICHD. Non sono emerse correlazioni significative fra comparsa della CG e fattori quali ciclo lunare e pressione barometrica.
Ritmi biologici nella cefalea a grappolo: studio prospettico a lungo termine su ampia casistica e proposta di revisione dei criteri diagnostici
BARBINI, JACOPO
2021/2022
Abstract
Introduction Cluster headache (CH) is a primary headache characterized by episodes of excruciating pain in the fronto-temporo-orbital area with strict one-sidedness, accompanied by local vegetative signs, lasting 15-180 min. The attacks are concentrated in periods of variable duration that define the active phase and discriminate the episodic from chronic form. The active phases tend to occur in the same patient with a seasonal rhythm and, within the cluster, the crises appear at stable times throughout the day with a circadian trend. Although frequently observed these characteristics have never been formally codified among the diagnostic criteria in the various editions of the International Classification of Headaches (ICHD) proposed by the International Headache Society (IHS). Aims of the study The study has the main purposes to detect seasonal rhythmicity in the appearance of clusters and a regular timing in the onset of attacks within the same active phase. Furthermore, a correlation between CH with the moon phases and the barometric air pressure has been investigated. Material and methods Patients who received a diagnosis of CH according to the ICHD criteria between April 2004 and October 2021 were instructed to promptly contact the Headache Centre on the first day of a new active phase onset and the data were prospectively collected in their clinical sheet. CH was diagnosed in 161 among the 4411 outpatients who referred for a first evaluation: 144 subjects (m: 105, 72.9%; f: 39, 27.1%; ratio m/f: 2.7; average age at CH onset: 37.4±15.3; average age at first evaluation: 46.8±15.0) received the diagnosis of 3.1.1 episodic CH (n=117) and 3.1.2 chronic CH (n=13); 14 presented an isolated active phase and, therefore, a third-level diagnosis was hampered; 17 were excluded because of lack of information (n=13) or modified diagnosis in further controls (n=4). Data concerning the day of appearance of a new active phase, time of onset of the attacks within the cluster and clinical features of the crises were prospectively collected. A total of 550 active phases (average duration 48.0±38.4 days; average intercritical interval was 16.9±28.6 months) was considered. Results A circadian pattern in the onset of the attacks was found in 128 patients (88.9%) with a peak prevalence between 02:00-04:00 p.m. (n=62; 43.1%) (p<0.05) and 02:00-04:00 a.m. (n=57; 39.6%). A seasonal rhythmicity of the appearance of the active phases was found in 71 among the 117 episodic CH sufferers (60.7%), more frequently during the springtime (n=42; 59.1%) (p<0.05) and autumn (n=26; 36.6%). Among them, a stable time of appearance of the attack within the same cluster was found respectively in 68/71 (95.7%) and in 37/46 (80.4%) subjects with predictable and unpredictable seasonality (p<0.05). No significant correlation was found between the beginning of cluster period and lunar phases or average atmospheric pressure. Ipsilateral lacrimation and conjunctival injection were the most frequent autonomic signs which accompanied the attacks (n=101; 70.1%), while miosis, eyelid oedema and sweating were very rare. Conclusion CH is confirmed to present regular biological rhythmicities, both in the seasonal onset of the active phase and in the appearance of the attacks at regular hours within the same cluster. Our results, in line with the literature, allow to propose the circadian patterns as additional tool among the diagnostic criteria of CH in the forthcoming revision of ICHD. No significant correlation has come to light between the beginning of clusters and factors such as lunar phase and barometric pressure.| File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/30892