Cluster headache vs. labor: A comparative perspective on acute pain during and after delivery

Cluster headache (CH), often nicknamed the “suicide headache” due to high rates of associated suicidal ideations, is considered one of the worst human experiences.1, 2 Patients routinely report debilitating pain and an accompanying sense of helplessness. In a study by Burish et al.,3 patients with CH were surveyed about other comparable types of pain they had previously experienced. Ranked second to CH was labor pain (childbirth); CH scored an average of 9.7 on a 0–10 numeric rating scale, compared to labor pain, which scored much lower at 7.2.3 Anecdotally, this seems to corroborate, as labor pain appears to be among the worst experienced by the general population; however, reports from this study were collected retrospectively. The reliability of patient recollection of prior painful experiences is limited by recall bias and the complexity of pain memory, complicating pain management strategies for future patients.4, 5 For patients who are pregnant and/or breastfeeding, high-flow 100% oxygen therapy via a non-rebreather mask and subcutaneous sumatriptan, with caution and obstetric consultation, are the first-line acute treatments. Verapamil and short-term oral prednisone/greater occipital nerve blocks are considered likely to be safe in pregnancy and breastfeeding.6 Here, we present two patients who experienced both CH and labor pains within close timeframes. Case 1 highlights a patient with a history of episodic CH and had cluster attacks during active labor. Case 2 highlights a patient who experienced an unfortunately timed cluster cycle that began just 5 days postpartum. Clinical details were obtained via direct patient interview and with review of their electronic health records. Both patients provided written informed consent to have their cases published. Our first patient was a 30-year-old female with a history of episodic CH who presented to our headache clinic at 7 days postpartum for acute management of an active cluster cycle. Her last cluster cycle had been 3 years prior to this presentation. Until the age of 20 years, she was misdiagnosed with ‘allergy headaches’ and migraine. She was advised to reduce allergen exposure, such as removing carpets, but these measures did not improve her symptoms. Ever since being properly diagnosed with CH, she has primarily relied on abortive treatments, including 100% high-flow oxygen therapy via a non-rebreather mask and subcutaneous sumatriptan, to manage her symptoms. Her headaches were severe, left-sided, periorbital, with associated left eyelid swelling, tearing, and rhinorrhea, typically occurring once daily and lasting for 4 weeks. She was referred to our headache clinic for an occipital nerve block to treat an active cluster cycle and was 7 days postpartum at the time of her visit. At 40 weeks gestation, the patient's cluster cycle began and continued into the days leading up to labor. She was seen by her primary care physician and urgently referred to a neurologist for management. Sumatriptan was prescribed and a new prescription for home oxygen was provided. She experienced a cluster attack while in the latent phase of labor in the emergency department. She started oxygen therapy in the examination room using the hospital supply; however, the CH pain was 10/10 in intensity, prompting her to take a dose of her home subcutaneous sumatriptan while in triage, which aborted the attack. A second severe cluster attack began after her first push during the active phase of labor in the delivery room. She reached for her home sumatriptan again, this time in the presence of the labor and delivery nurses. Despite the surprise and uncertainty of the nurses, the patient self-injected, successfully aborting the attack and enabling her to continue pushing and completing the delivery of a healthy male infant, without notable adverse effects to the infant or patient. Of note, the patient elected not to receive additional pain medications (i.e., epidural) during labor and delivery. At 1 week postpartum, the patient presented to our headache clinic to discuss treatments for the ongoing cluster cycle. She was treated with an ipsilateral occipital nerve block with corticosteroid. Reflecting on her experience, the patient shared that she was hesitant about the use of her prescribed cluster medications in the birthing unit, and that it might have disqualified her from proceeding with a natural vaginal delivery. Consequently, she did not inform the labor nurses that her family had brought her injectable sumatriptan, as she was in an active cycle. Her family was familiar with her condition; however, as noted above, the hospital staff may have been unfamiliar with CH and were surprised that she self-administered her medication at this time. This was likely due to hospital protocol with the use of home medication, concern for potential for adverse effects, and not fully grasping the seriousness of her head pain and overall state of desperation. She described the overwhelming experience of having to endure both of the worst pains in her life simultaneously and that the CH pain was much worse than the labor pain, despite no epidural use. Our second patient was an established 28-year-old female who presented to our headache clinic as a follow-up to her CH diagnosis. She was initially misdiagnosed with migraine in her early 20s, similar to our first patient and many others with CH. This patient's headaches were right temporal and periorbital, occurring every other day, lasting 3–4 h, with a pain intensity rating of 10/10. Attacks were associated with significant restlessness, agitation, ipsilateral ptosis, and lacrimation. Cycles for this patient lasted ~1 month on average and were followed by remission periods of ~6 months. The patient had an uncomplicated first pregnancy and delivered a healthy male infant at 37 weeks gestation. A cluster cycle started 5 days after delivery, prompting her presentation to our headache clinic for treatment. Given that she was actively breastfeeding, she was recommended to continue oxygen, sumatriptan injections (with instructions to pump and discard the breast milk for the first 4 h after use as a precaution) for acute treatment, and oral prednisone and verapamil as preventatives. She was requested to first receive clearance from her child's pediatrician before initiating these treatments. During her clinic visit, she revealed that she had purposely chosen not to have an epidural during childbirth. She stated, “Dr. Ali, you told me that cluster headache pain is worse than labor pain. I wanted to see if you were right, so I chose not to have an epidural and test to see if cluster pain is indeed worse than labor pain.” Upon experiencing a recurrence of cluster in the immediate postpartum period, she was able to easily compare the pain levels of each. She stated that CH pain was the worst she has ever had. She said, “I would rather give birth 16 times in 1 day,” when explaining her preference to labor pain over pain from cluster attacks. We share the experiences of two patients who faced the unfortunate timing of cluster attacks during active labor (Patient 1) and in the immediate postpartum phase (Patient 2). Our first patient provides a unique firsthand, direct, and unprecedented comparison of the “worst human experience” with the pain of active childbirth. This is the first such report, per our review, which offers valuable insights into the subjective nature of pain perception and intensity. Our second patient demonstrates the resilience, curiosity, and extreme lengths that patients with CH often go to. She chose to forego pain medication during childbirth to better understand her condition and the reported experience of other patients with CH. Beyond pain, their shared experience underscores the disastrous impact of this condition, only exacerbated by its unpredictable timing. They respectively share their stories of how they experienced two simultaneous and near-simultaneous debilitating pain conditions. The close temporal relationship between their cluster attacks and labor allows for a more accurate comparison between the two painful experiences with less recall bias. However, direct pain comparisons only tell a part of their story. There is an emotional element that is difficult to measure. One can only imagine the overall burden—physical, psychological, and emotional—of a cluster cycle that undesirably shows its face in peripartum. Pregnant individuals in general often take great care to ensure adequate preparation for this period. They pack belongings well in advance, arrange childcare (for other children), block out all other responsibilities, and have a backup plan for their backup plan. Their friends and family provide support and sympathy, send gifts, set up meal-trains, and exemplify generosity. But how does one account for the stubborn and inconsiderate timing of a cluster cycle or its individual attacks? Why must it be so insensitive? And of course, the weeks after delivery are essential for the wellbeing of both the mother and child. Patient 1 emphasized to the authors that living with CH as a mother requires extraordinary family support. She expressed concern about her ability to raise her child while managing this debilitating condition. Patient 2 described her internal struggle about how she would continue to breastfeed her child considering the medications she would need for CH. As clinicians, we can only begin to imagine the experiences of patients with CH. It presents itself whenever it wants. It is inconsiderate, stubborn, and has no regard for your dreams, ambitions, responsibilities, or current circumstances. It does not care if you are already trialed with another difficulty, hospitalized for another condition, taking shelter in a war zone, have just lost your job, or are grieving the loss of a loved one. CH is like an unwanted guest; it shows up uninvited, makes a mess of the place, and then leaves only threatening to come back later – and on its time, not yours. Study concept and design: Joudi Sharaf, Ashhar Ali. Acquisition of data: Joudi Sharaf, Ashhar Ali. Analysis and interpretation of data: Joudi Sharaf, Ashhar Ali. Drafting of the manuscript: Joudi Sharaf, Ashhar Ali. Revising it for intellectual content: Joudi Sharaf, Ashhar Ali. Final approval of the completed manuscript: Joudi Sharaf, Ashhar Ali. Joudi Sharaf and Ashhar Ali have no conflicts of interest.