Cluster Headache Diagnosis

[HeadPain]

Question: Based on the information below is Cluster Headache (cause unknown as I understand) the most probable accurate diagnosis or are there other possible more cause specific possible diagnosis? Depakote medication does not seem to be working for me.


Hstory of recent (2008) symptoms:
March/April slight random tingling in left side of my head, left arm, left leg.

April, progressive fatigue begins and worsens (very unusual for me).

May, left side of face feels numb at times but no constant. Left half of lips feel "lazy" and numb at times but not constant

Mid June I had a mild chest cold which went away after a week or so.

End of June I had a sudden left ear ache (pencil driving into my left ear) with severe left temporal area headache. Numbness in face and lips returns and remains. Tingling becomes more recuring. Urgent Care doctor diagnosed ear infection, prescribed antibiotics and pain medication. Sever headache disapated to be constant (about a 3 on scale of 0 to 10) with random severe headaches (a 12 on a scale of 0 to 10). Severe headaches make my left eye hurt severely and water. Severe headache episodes are random and pain engulfs the left side of my head down to my neck.

July, headaches persist, ear aches returns. Family doctor diagnosed ear infection and prescribes same regiment as Urgent Care doctor. Ear pain relieved but other symptoms remain. Family doctors tells me to see an Ear, Nose & Throat (ENT)specialist. Overly warm rooms (summer heat with no air conditioning) maky symptoms worsen. Casual social alcohol bring on severe headaches instantly.

Sept, ENT visit with continued symptoms. Speech is somewhat slurred as reported by my offiice Admin. Thought process is quicker than my words coming out of my mouth - I stumbled over words at times. Hearing test confirms my long term (20+ years) of deficient higher mhz range hearing in left ear (I can not hear crickets in my left ear). ENT orders an MRI with contrast of auditory canal looking for acoustic neuroma. MRI report notes no acoustic neurome but identifies 2 lesions: 1-19 mm left periventrical leison, 1-9mm right side occipital lobe leison. ENT suggests I see neurologist. Radiology report suggests "....possible early stage Multiple Sclerosis..."

Oct, Neurologist reads MRI images and finds possible third leison "shadow". I am told symptoms suggest no MS by location of leisons as well as 3 leisons is below the MS specific 6 for qty to be considered MS and MS symptoms do not worsen with alcohol (see above). Suggests diagnosos is Cluster Headache...this type of headache reacts to alcohol instantly. Neurologist orders a host of blood tests (including lime disease) and MRA brain scan, no contrast. Prescribes Depakote 500 ER once daily, Prednisone (high dose for one week / step down doseage second week until finished) and Imitrex at onset of severe headache episodes with a follow-up Imitrex 2 hours after the first.

Nov, Blood tests all normal. MRA normal. Neurologist suggesting Spinal Tap but will not be ordered until next office visit in December.

Response to medications: Slight softening of constant headache for 2 to 3 hours of the morning. Severe headache (left temporal area) episodes continue randomly without eye specific pain and watering of eye (left side). Numbness in left side of face continues, constant left temporal area headache continues, lazy left side of lips and numbness unchanged. Left jaw muscle seems weak (new) and mouth bite not aligned (right side teeth hit before left). Had cracked tooth, root canal and crown on top right tooth last month. Speech continues to be slurred randomly and mental processing seems "slow" at times. My morning walk time from commuter train to office has slowed from 10 minutes to 12 minutes on the average over the past 3-4 months. tingling in left side noted previously continues randomly.

Statistics of self:
Age: 48

Gender: Male

Occupation: Structural engieer / Office Manager of branch office, Chicago

General health: Good. Blood pressure always excellent (even now) at 110/70. Heart rate always 76 or so.

Previous injuries / surgery:
1976 to 2006 various right knee surgeries, current degen arthritis.
1977 automobile accident with whip lash. Numbness in both arms for 18 month period before full recovery.
1996 Broken right wrist from fall from single story roof to pavement. Right arm nerve compression from injury with surgery for nerve decompression of anterior anterosios nerve (spelling is likely not right with the nerve).
1998 Spinal fusion L5-S1, surgery from back side.

Thank you in advance for your thoughts,

HeadPain

[John Kenyon, CNA]

Hello -

While your history and symptoms certainly do fit a possible diagnosis of cluster headache, there are questions raised by the lesions (plaques?) found on your brain, even though the are apparently quite small. It also sounds as though you may be having irritation of one of the cranial nerves in addition to cluster headaches, based on your description of the sudden, sharp pains in the ear on the affected side. This could be related, if there is an underlying cause, or it could be coincidence.

It would seem appropriate to seek a second opinion, not so much because cluster headache doesn't seem like a viable diagnosis, but rather that it seems there is more than just that going on. There may not be, but it certainly would be worthwhile to know.

I hope this is helpful to you. Best of luck. Please keep us updated.

[HeadPain]

Follow-up appt with my neurologist notes the following change in overall diagnosis:

He took notes on my report of present conditions and the effect that Depakote has had with me (softening my head pain).

He did a brief exam. We discussed the results of the blood tests and MRA brain scan. He found nothing of significance in the blood test results. After receiving the radiology report he requested the scan images to study himself. He said he found a slight thickening of the artery wall on the left side in the images (whatever it is called). His take on it this is early Athero / Arteriosclerosis.

He said he studied the MRI scan again in length since I last saw him in October. All things considered - the effect of the Depakote, the long term nature of my headaches, my numerous other symptoms (noted above), the findings of the MRA - he now gave a diagnosis of early MS with Arthero / Arteriosclerosis of the cerebral artery on the left side of my brain. Rate of progression is undertermined for both.

I am to continue on the Depakote and add 81mg aspirin tablet daily. My next appt. is in June unless I have symptomatic changes.

I will be on meds now forever and require MRA and MRI scans yearly to check for changes with the 2008 scans as the baseline.

Sound right ?

As much as my neurologist comes high recommended, would a second opinion be worthy?

Thank you for your input,
HeadPain