Cluster Headaches

The International Headache Society classifies cluster headaches as belonging to a group of trigenino-autonomic cephalgias. The headaches typically occur as clusters of attacks, short-acting, very painful, affecting one side of the head. The World health Organization states that cluster headache is relatively rare compared to migraine, affecting less than 1 in 1,000 adults. cluster headache

Men are more prone to cluster headaches than women at least at a ratio of 4:1 and the onset is often between the ages of 20 and 40. However, in some patients, this condition becomes less severe with age.

Causes

There is no specific cause but genetic factors are being studied to ascertain the familial incidence. It appears that the hypothalamus is involved, leading to the seasonal or clock like nature of the episodes which can strike at the same time of the year. Positron emission tomography (PET) has been used to substantiate the activation of the hypothalamus in attacks. Cluster headache has episodic and chronic forms.

Unlike migraines, cluster headaches aren't associated with triggers such as some foods or lack of sleep. However, both alcohol and nitroglycerin (used to treat heart disorders) can trigger attacks.

Signs & Symptoms

It can take a long time for patients to get an accurate diagnosis and treatment, so being aware of the accuracy of reporting symptoms to doctors may assist. Some of the signs and symptoms include:

  • Episodic cluster headache – short eg 15 minutes to a few hours of severe pain, occurring daily. onset can be sudden waking the patient at night, lasting weeks or months, and then a headache free period of different durations
  • One sided headache, located around the eye which may be described as intense burning, sharp or penetrating and can include watering of the eye
  • Stuffy or runny nose
  • Restlessness or agitation

Although cluster headaches and migraines are both severe, the other differing factors for cluster headaches include:

  • The relatively short duration of attacks* May have a lack of nausea or vomiting
  • May not be associated with light or sound sensitivity
  • May pace through the attack with lying down tending to increase the pain

Treatment and management

Inhaling pure (100%) oxygen is effective in reducing the severity of attacks in many patients. Oxygen is a safe treatment as long as there are no naked flames present.

The 'triptan' group of medicines may also be effective and can be administered by injection or intranasally. These selective serotonin agonists cause vasoconstriction of the cranial vessels and can reduce the severity of the headache relatively quickly when injected.

Given that many patients can have multiple daily attacks, it is important that preventive measures are considered for chronic and episodic cluster headaches. The mainstay is verapamil, a calcium channel blocker which is often well tolerated and is also used to treat hypertension and angina. Prednisone, a steroid, is often effective in in the first stages of treatment but has too many serious side-effects to be used long-term.

There are other interventional or surgical techniques which may be considered if the cluster headaches don't respond to pharmacological treatments such as occipital nerve stimulation. The surgeon connects electrodes to the back of the head with leads to a small generator that changes the brain's electrical impulses. This may block or reduce the pain signals.

Deep brain stimulation of the hypothalamus is also being studied as a potential option for patients with chronic cluster headaches, unresponsive to medication. A long-term Italian trial found many patients improved and some maintained the benefits even after the stimulation had been turned off, suggesting that the stimulation could reverse the headache state. However, this technique is associated with substantial risk.

At this stage, there isn't one treatment that suits every patient. Cluster headaches are not life threatening, although severe, and, as researchers understand more of the key roles of the posterior hypothalamus and, secondly, genetics, these systems may be targeted by medications in the future.

The ‘triptan’ group of medicines may also be effective and can be administered by injection or intranasally. These selective serotonin agonists cause vasoconstriction of the cranial vessels and can reduce the severity of the headache relatively quickly when injected.

Given that many patients can have multiple daily attacks, it is important that preventive measures are considered for chronic and episodic cluster headaches. The mainstay is verapamil, a calcium channel blocker which is often well tolerated and is also used to treat hypertension and angina. Prednisone, a steroid, is often effective in in the first stages of treatment but has too many serious side-effects to be used long-term.

There are other interventional or surgical techniques which may be considered if the cluster headaches don’t respond to pharmacological treatments such as occipital nerve stimulation. The surgeon connects electrodes to the back of the head with leads to a small generator that changes the brain’s electrical impulses. This may block or reduce the pain signals.

Deep brain stimulation of the hypothalamus is also being studied as a potential option for patients with chronic cluster headaches, unresponsive to medication. A long-term Italian trial found many patients improved and some maintained the benefits even after the stimulation had been turned off, suggesting that the stimulation could reverse the headache state. However, this technique is associated with substantial risk.

At this stage, there isn’t one treatment that suits every patient. Cluster headaches are not life threatening, although severe, and, as researchers understand more of the key roles of the posterior hypothalamus and, secondly, genetics, these systems may be targeted by medications in the future.

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