[Symptomatic cluster headache: presentation of 2 cases]

Cluster headache is a primary headache with well-defined diagnostic criteria. Nevertheless, in 3-5% of patients this syndrome is secondary to diverse cranial structural abnormalities. Atypical features which suggest a secondary or symptomatic origin include absence of periodicity and regular hourly recurrence, persistence of background pain among attacks, unsatisfactory response to treatment, and presence of neurological signs other than ptosis or miosis. We present two patients with symptomatic cluster-like headache. In one, the syndrome was associated with a fistula of the right superficial temporal artery. After embolization the pain attacks ceased. The second patient presented a ventricular xanthoma, located in the occipital horn; after surgical excision, the pain attacks did not recur. The progressive increase in frequency and absence of regularly hourly recurrence of pain episodes was a common feature in both cases. We comment and revise the pathophysiology of this syndrome, with emphasis on the case of the xanthoma, since we did not find a similar case described. If a secondary cluster-like headache is suspected, neuroimaging studies should be done.