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Cluster Headaches: Understanding and management

Pain, General | June 28, 2015 | Author: The Super Pharmacist

general, Pain

Cluster Headaches: Understanding and management

Cluster headaches are a distinct subtype of headaches, with a prevalence of about 0.1%. They are associated with pain in certain areas of the face and skull that may be severe and/or chronic. Pain typically occurs in multiple attacks in relatively rapid succession. These may occur over the course of a single day or within a week. The exact cause of these headaches has not been fully defined; however, they appear to be associated with the dysfunction of pain regulation within the central nervous system. Certain major nerves travelling to and from the brain (peripheral nerves) also may have some involvement. This indicates that cluster headaches may fall into the category of primary headache disorders (pain in the head or face that is not associated with a factor such as an underlying illness). This has been supported by recent neuroimaging studies. The origin of this disorder is not fully understood, but may be determined by genetics. Cluster headaches also seem to be linked to activity in areas in and around the hypothalamus of the brain, which control the circadian ('body clock' or 'daily') rhythms of the body. This may explain the repetitive nature of this condition. Cluster headaches are attacks of usually intense pain that are often felt over only one eye, in one temple (side of the head) or both one eye and one temple. They may last anywhere from 15 minutes to two hours. The 'clusters' for which the conditions are named are multiple attacks of this pain. Clusters may be up to eight in number, sometimes occurring in the space of one day.

Characteristics of Cluster Headaches

Cluster headaches are often misdiagnosed as other headache types, such as migraine. However, this condition has some non-pain symptoms that tend to distinguish it from others. These may include:

  • Watering of the eye on the side of the head affected
  • Swelling in the lid of the same eye
  • Reduced ability to keep the eye open
  • Pupil constriction
  • Nasal stuffiness and/or running

There are two main types of cluster headache:

  • Chronic cluster headache: This involves regular attacks of clusters that may last a year or more, non-stop.
  • Episodic cluster headache: These are attacks of headache that proceed over the course of a few weeks or months, and then remit only to recur again in roughly the same pattern.

Some data indicates that cluster headaches may persist for up to 16 years. Cluster headaches have been observed to have an association with sleep disorders. A study of 275 patients found that their sleep quality was significantly impaired, and that this was associated with cluster headache onset. On the other hand, sleep disturbance is also associated with other headache disorders, such as tension-type headaches. Cluster headaches may also be accompanied by additional hallmarks shared by other conditions such as chronic migraine, such as photophobia. A recent study demonstrated that some patients diagnosed with cluster headaches also exhibited separate symptoms associated with a different headache disorder (trigeminal neuralgia). This may contribute to the delay before accurate diagnosis of cluster headache, which has been reported to have an average duration of seven years.

Treatment options

Patients with cluster headaches may respond to some conventional and interventional forms of treatments. These include:

Drug Therapy

Pharmaceuticals, administered orally or otherwise, are a part of conventional treatment for cluster headache.

  • Sumatriptan: This is a classic antidepressant that has more recently been shown to be effective as a painkiller in primary headache disorders. It is often delivered in the form of a nasal spray, but may also be injected under the skin (i.e. subcutaneously) to address the onset of pain in cluster headaches. A double-blind trial randomised 118 patients to intranasal sumatriptan or placebo, in a way that 77 attacks were treated with the drug and 77 with placebo. The headache response rates at 30 minutes after administration were significantly higher for sumatriptan than those for placebo9. A review of six studies on this and similar drugs included 131 participants given 6mg subcutaneous sumatriptan. 75% of these reported no pain or mild pain 15 minutes after administration.
  • Zolmitriptan: This is another drug in the same class as sumatriptan (i.e. the triptans). It has also been observed as being of some use in the treatment of cluster headaches. Like sumatriptan, it is indicated as an intranasal application in acute cluster headache. A double-blind cross-over trial compared the efficacy of 5mg, 10mg and 0mg (i.e. placebo) intranasal zolmitriptan on three separate attacks in the same 69 adult patients. The response rates (% pain reduction 30 minutes post-administration) for the two doses were significantly higher compared to placebo. However, these responses were far more pronounced in patients with ECH than with CCH; e.g. the rates of headache relief in those with ECH were 80% for 10mg zolmitriptan, compared to 36% for those with CCH given the same dose.
  • Veraprimal: This is a calcium-channel blocker used in the prevention of cluster headaches. The recommended dose of this drug is typically between 480 and 720mg daily, although 360mg a day has been shown to be effective for patients with cluster headache in clinical trials.
  • Indomethacin: This is a non-steroidal anti-inflammatory drug, associated with effective pain relief in some cases of cluster headache.

Surgical therapy

Neuromodulation In some cases, patients may not respond to these treatment options as above. This is known as refractory or treatment-resistant cluster headache, and may involve considerable debility for the patients affected. Adequate pain relief in these instances may require invasive surgeries that implant devices to correct the 'pain' signals emitted by nervous tissue thought to be associated with cluster headache. These interventions may result in medium- to long-term relief from this condition, including a return to normal function and life quality. These techniques are known as neuromodulation (or nerve stimulation) and are an increasingly well-regarded method in the management of many chronic and/or severe pain conditions. Neuromodulation procedures associated with a positive effect in cases of cluster headache include:

  • Peripheral Nerve Stimulation: Some peripheral nerves located in the skull or spine appear to have the ability to regulate or modulate pain disorders originating in the central nervous system. Therefore, stimulation of these using devices that emit small electrical impulses may modulate the pain signals of the brain. A prominent target of this is the occipital nerve. Targeting this nerve has had some success in treating disorders like migraine. Early studies of this procedure (occipital nerve stimulation) indicated it may also be of use in cases of cluster headache. A trial of four adult patients with long-term cluster headaches underwent this procedure. This resulted in a 49% decrease in headache intensity and a 64% decrease in their duration. In addition, the medication intake of these patients was significantly reduced.

Neuromodulation may seem an extreme step to take, but the surgeries associated with this treatment are minimally invasive, using modern equipment and electrode devices. Complications and adverse events are rare, and the patient is rarely disturbed or inhibited by the presence of the implants, as they are placed under the skin and are not usually visible or obtrusive.

  • Nerve Blocks: These are procedures in which the pain-processing signals of the peripheral nerve in question are inhibited by injecting drugs such as local anaesthetics into their vicinity. This may effectively treat pain in many headache disorders. The target of these nerve blocks is often the occipital nerve.
  • Occipital Nerve Block: A study of 60 patients receiving this treatment found that approximately 80% of the nerve blocks performed resulted in a decrease of attack intensity, duration and frequency. This lasted for an average of 3.5 weeks for patients with CCH. For those with ECH, the duration of effect was less clear, but appeared to last about as long as the 'episode' of cluster headache concerned.
  • Oxygen Therapy: The inhalataion of high-flow oxygen is regarded as another effective treatment for cluster-type headache at its onset.
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References

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Friberg L, Sandrini G, Perrotta A. Neuroimaging and clinical neurophysiology in cluster headache and trigeminal autonomic cephalalgias. Handbook of clinical neurology. 2010;97:413-420.

Shimazu T. [The recent pathophysiology of cluster headache (trigeminal autonomic cephalalgias; TACs)]. Rinsho shinkeigaku = Clinical neurology. 2013;53(11):1125-1127.

Weaver-Agostoni J. Cluster headache. Am Fam Physician. 2013;88(2):122-128.

de Quintana-Schmidt C, Casajuana-Garreta E, Molet-Teixido J, et al. [Stimulation of the occipital nerve in the treatment of drug-resistant cluster headache]. Revista de neurologia. 2010;51(1):19-26.

Barloese M, Lund N, Petersen A, Rasmussen M, Jennum P, Jensen R. Sleep and chronobiology in cluster headache. Cephalalgia. 2015.

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van Vliet JA, Bahra A, Martin V, et al. Intranasal sumatriptan in cluster headache: randomized placebo-controlled double-blind study. Neurology. 2003;60(4):630-633.

Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database Syst Rev. 2013;7:CD008042.

Cittadini E, May A, Straube A, Evers S, Bussone G, Goadsby PJ. Effectiveness of intranasal zolmitriptan in acute cluster headache: a randomized, placebo-controlled, double-blind crossover study. Arch Neurol. 2006;63(11):1537-1542.

VanderPluym J. Indomethacin-responsive headaches. Curr Neurol Neurosci Rep. 2015;15(2):516.

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Gantenbein AR, Lutz NJ, Riederer F, Sándor PS. Efficacy and safety of 121 injections of the greater occipital nerve in episodic and chronic cluster headache. Cephalalgia. 2012;32(8):630-634.

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