Abstract
Introduction
Patients suffering from cluster headache (CH, International Headache Society (IHS) code 3.1) often show mood changes, in particular depressive reactions. This observation from clinical practice still lacks systematic evaluation in controlled studies as does comorbidity of CH and affective disorders (AD) in general (1). Only few data exists from studies mainly focused on depression and/or on other types of primary headaches (mainly migraine) (2–4). Only some of them included a small number of CH patients. Nevertheless, some patients with CH and bipolar AD share common features such as a similar temporal pattern, a change in secretion of melatonin in CH (5–7) and in AD (8–10), altered erythrocyte cholin concentration (11) and response to the same pharmacological treatment (12–15).
We report on a, to date, episodic depressive patient who developed his first manic episode while he suffered from a cluster episode.
Case report
A male patient was admitted to Münster University Hospital for the first time at the age of 13 in October 1965 when he suffered from nocturnal enuresis. A neurotic development was discussed. After treatment including approaches using learning theories, he recovered from enuresis and was followed in the psychiatric outpatient clinic.
In March 1966, the patient complained for the first time about short, sharp headaches, intermittent blurred vision, biting pain of several other regions of his body and intermittent paraesthesia of arms and legs. The neurological examination was unremarkable.
He completed secondary school in 1966 followed by a vocational training as orthopaedic mechanic. For several years, he worked in different jobs as an unskilled worker and consumed regularly alcohol, cannabis, cocaine and lysergic acid diethylamide (LSD). Since 1979, he has been working as employee in an administrative authority in his birthtown. Still living close to his parents it was only from 1984 to 1986 that he lived in his own apartment. Our patient returned to the parental home due to severe financial problems after excessive gambling where he is still living with his mother.
In 1990, he was hospitalized for the first time in our neurological department because of severe headaches, which had occurred previously for several years and were mainly located behind the left eye. The diagnosis of episodic cluster headache was established according to IHS-criteria (16).
During this hospitalization, the diagnosis of a depressive disorder was established by the Department of Psychiatry.
Between 1991 and 1995, CH episodes lasting three to eight months were treated with a prophylactic medication consisting of verapamil (360–420 mg daily) and either methysergid (8 mg daily, 1991), lithium (1350 mg daily, 1992 and 1993) or prednisolone (50 mg daily for five days with consecutive tapering off, 1993, 1994 and 1995). Acute treatment comprised oxygen and subcutaneous sumatriptan.
In November 1998, another episode of CH with nocturnal headaches of the left periorbital region lasting 90–180 min started. A treatment with 125 mg methylprednisolone was initiated but no relief from headaches occurred. After four weeks, the patient was transferred to our hospital. The patient's history revealed severe sleep disturbances as well as a weight gain of 6 kg during corticoid therapy. The neurological examination was again unremarkable. The P 300 component of the event-related potentials was delayed to 534 ms which is typical during an acute cluster episode (17). Two ECGs were within normal limits. Verapamil was started to reach a final dose of 80 mg four times daily. Methylprednisolone was reduced during this hospitalization to 20 mg per day. The patient left hospital after four consecutive days without headache.
After discharge, the diagnosis of a manic psychosis was established because of insomnia, flight of ideas, euphoric affectivity with manic excitation, and lost of understanding of his illness. Suicidal ideas and the possibility of endangering other people led to his hospitalization in the Department of Psychiatry under legal conditions. The maximal score on the Bech-Rafaelsen mania assessment scale was 29 (18).
The psychotic disorder regressed 24 h after the start of treatment with sodium valproate and levomepromazine. Up to three cluster headache attacks per night were treated with oxygen inhalation or sumatriptan. Methylprednisolone was reduced to 15 mg on discharge from psychiatry. The patient re-entered our clinic with valproate 500 mg three times daily.
A fluorine 18 deoxyglucose (F-18-FDG) positron-emission tomography scan showed neither focal nor general alteration of metabolism of glucose.
At discharge, the patient received 1500 mg valproate and 560 mg verapamil daily. CH and mania disappeared. He is now symptom-free for more than one year.
Discussion
Cluster headache is a severe and often disabling primary headache which may lead to depressive mood in patients suffering either from the episodic or the chronic type of the illness. Only very few studies evaluated the impact of primary headaches such as migraine, chronic tension-type headache, or CH on the mood of the affected patients. Relatively small numbers of patients have been assessed either from the neurological point of view of a headache clinic looking at alterations of mood (4) (unfortunately without differentiation of main headache subtypes since this observation had been undertaken before the introduction of the IHS criteria) or on the other hand from the psychiatric perspective of primarily psychiatric patients and their comorbidity of headaches: 51.9% of a population of 160 patients suffering from major depression or bipolar disorder also complain about primary headaches in general and 1.2% complain about CH (3). A longitudinal cohort study of 379 subjects found a strong association between migraine and depression and anxiety disorders (2).
To our knowledge, this is the first report on the onset of manic symptoms during a CH episode. We believe that the manic symptoms were induced by steroids or by steroid withdrawal. Several cases of affective psychosis, including mania, following administration or cessation of steroid-like molecules have been reported (19–23).
We also believe that the patient with his previous history of recurrent depression and his known hyperthymic temperament (24) belonged to the ‘soft bipolar spectrum’ (25) and that therefore his vulnerability for drug-induced mania was increased.
Valproate is an established treatment in bipolar disorders (12, 26) including acute mania (27). Its use in CH is widely practised since the publication of an open pilot study including 15 patients by Hering et al. in 1989 (14). However, there are no controlled double-blind studies to confirm their findings. Alternatively lithium can be used in both diseases (15). We recommend not to apply corticosteroids in CH patients suffering also from affective diseases.