Number and Severity of Cranial Autonomic Symptoms Differ Based on Cluster Headache, Migraine Aura Status


On average, those with cluster headache had 4.8 cranial autonomic symptoms compared with 2.7 for those with migraine, regardless of aura status.

Jr-Wei Wu, MD

Jr-Wei Wu, MD

In a prospective study comparing patients with cluster headache (CH), migraine with aura (MA), and migraine without aura (MoA), investigators found significant differences in cranial autonomic symptoms (CAS) between the groups, with more frequent and severe symptoms found in those with CH.Lead investigator Jr-Wei Wu, MD, attending neurologist, Taipei Veterans General Hospital, and colleagues concluded that, "deep phenotyping of CAS can improve diagnostic accuracy and help with the understanding of the pathophysiology of CH, MA, and MoA."1

Presented at the 2022 American Headache Society (AHS) Annual Meeting, June 9-12, in Denver, Colorado, the study recruited 26 patients with MA, 76 with MoA, and 20 with CH who completed a standardized questionnaire that included 9 different symptoms and a CAS severity score. The severity of each symptom, including conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, and forehead/facial sweating was graded as either absent, mild, moderate, or severe.

In total, the highest proportion of patients with at least 3 CAS were those with CH (85.0%), followed by patients with MA (61.5%) and MoA (44.7%), a difference that was significant (P = .0006). In comparison with migraine in general, patients with CA had both a higher number of CAS (4.8 [±2.1] vs 2.7 [±2.6]; P <.001) and CAS severity score (6.1 [±3.6] vs 2.7 [±2.6]; P <.001). In migraine, MA had a higher CAS number than MoA (MA vs MoA: 3.6 [±2.7] vs 2.3 [±2.0]; P = .034), but there were no differences in the severity score.

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Conjunctival injection and lacrimation, both found in 75% of patients with CH, were significantly higher in that group than in MA, which reported rates of 34.6% and 42.6%, respectively, and MoA, for which 31.6% of both symptoms were found (P <.05 for all between-group comparisons). Among patients with migraine, rhinorrhea, ptosis, and ear fullness were more commonly reported in MA than MoA (P <.05 for each comparison).

The associations between CAS and more severe disease have been researched before, included one 2021 study from Togha et al, which suggested that diagnosis of CAS could lead to the possible evolution of chronic migraine.2 That study, which featured more than 900 patients who presented with migraine, showed that about 70% of subjects with chronic migraine and 56.2% of those with episodic migraine reported at least 1 CAS. The 2 most commonly reported autonomic symptoms were eye redness (36.06%), and tearing (21.02%). Chronic migraine (43.4% vs 29.5%), unilateral headache (56.8% vs 48.7%) and blurred vision (20.0% vs 14.7%) were significantly more frequent in migraineurs with CAS.2

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1. Wu J, Chen S, Chiang C. Deep phenotyping using cranial autonomic symptoms in migraine and cluster headache. Presented at: AHS Annual Meeting, 2022; June 9-12; Denver, CO. P-14.
2. Togha M, Jafari E, Moosavian A, Farbod A, Ariyanfar S, Farham F. Cranial autonomic symptoms in episodic and chronic migraine: a cross sectional study in Iran. BMC Neurol. 2021;21:493. doi:10.1186/s12883-021-02513-0.
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