Cluster headaches

Primary headache syndrome with unilateral severe pain usually in the eye, periorbital region, and temple with associated cranial autonomic symptoms such as conjunctival injection, lacrimation, nasal blockage, rhinorrhea, ptosis, and eyelid edema.

A trigeminal autonomic cephalgia.

Prevalence of about 1 in 1000 persons.

Male: female ratio is 5: 1.

Often begin between second and fourth decades and consist of severe unilateral pain lasting anywhere from 15 to 180 minutes associated with lacrimation, nasal rhinorrhea or stuffiness, and occasional miosis, ptosis, and salivation.

Patients are often agitated and restless during the attack.

Frequency of attacks usually vary from one every other to for up to 8 attacks per day.

Most headaches are nocturnal.

Attacks last between 15-180 minutes when Untreated and can occur once or several times per day during cluster headache periods that can last for weeks to months.

Attacks may occur at a regularly time during the day and may be precipitated by sleep, usually occurring 90 minutes after the onset of sleep.

Attacks occur in clusters, lasting for weeks or months, separated by remissions lasting months to years.

Episodic cluster headaches defined as attacks lasting 7 days up to a year, with breaks of 1 month or more between bouts.

Bouts usually occur once a year, with a bout duration of 8 weeks.

Chronic cluster headaches ref2242ed to headaches occurring for more than one ear without remission or with remissions lasting less than 1 month.

Episodic cluster headaches are more common than chronic variety, affecting 75-90% of patients.

An extreme type of pain.

Can adversely affect quality-of-life, daily functioning, and ability to work.

Suicidal ideation has been reported during periods of cluster headache.

PET scan has identified focal increase in blood flow in the ipsilateral hypothalamus during attacks (May A et al).

Treatment is aimed at terminating attacks and preventing or reducing the frequency of recurrent events.

Most effective treatment is sumatriptan, a serotonin, 5-hydroxytryptamine receptor agonist.

Sumatriptan 6 mg subcutaneously effective as early as 15 minutes after administration(Ekbom K).

Sumatriptan 20 mg by nasal spray is effective management at 30 minutes after dosing.

Zolmitran 10 mg orally ffective at 30 minutes after treatment, while intranasal zolmitripan 5 and 10 mg are effective after 30 minutes.

Triptans such as sumatriptan are limited in usage to 2 subcutaneous injections or 3 nasal sprays a day t prevent tachyphylaxis and/or rebound.

Triptans agents are contraindicated in the presence of vascular disease, such as ischemic heart disease.

Other therapies include high dose verapamil, and lithium.

Galcanezumab is a human is the monoclonal antibody that selectively binds to calcitonin generated peptide and inhibits its activity: when administered subcutaneously at 300 mg monthly can reduce the weekly frequency of attacks in episodic cluster headaches (Goadsby P).

As many as 20% of cases are medically refractory.

High-flow oxygen can be used without toxicity, in combination with other therapies and multiple times during the day as a treatment for cluster headaches.

The inhalation of 100% oxygen for 15 minutes after the start of an attackcan abort such attacks (Kudrow L).

In a double blind, randomized placebo controlled crossover trial of 109 adults with cluster headaches treated with high-flow oxygen or placebo, alternately: at 15 minutes 78% of patients treated with high dose oxygen were pain free while 20% of placebo patients were pain free(Nyweide D).

Deep brain stimulation of the hypothalamus may be successful for refractory disease.

Leave a Reply

Your email address will not be published. Required fields are marked *