Cluster Headache - Diagnosis and Treatment
Cluster Headache - Diagnosis and Treatment
US Neurology Review 2005
Published: October 2008
Published: October 2008
The face of cluster patients has been described as having a ‘leonine appearance’ with thick, coarse facial skin, peau d’orange appearance, marked wrinkling of the forehead and face with deep furrowed brows. In addition, Kudrow 4 reported that two-thirds of the patients in his large series had hazel colored eyes.These features may actually reflect a history of smoking and alcohol overuse, which is common in cluster sufferers.
Table 1: Abortive Treatment Options
Treatment
All cluster headache patients require treatment. Other primary headache syndromes can sometimes be managed non-medicinally but in regard to cluster headache medication, sometimes even polypharmacy is indicated. Cluster headache treatment can be divided into three classes. Abortive therapy is a treatment given at the time of an attack for that individual attack alone. Transitional therapy can be considered an intermittent or short-term preventive treatment. An agent is started at the same time as the patient’s true maintenance preventive. The transitional therapy will provide the cluster patient attack relief while the maintenance preventive is being built up to a therapeutic dosage. Preventive therapy consists of daily medication that is supposed to reduce the frequency of headache attacks, lower attack intensity, and lessen attack duration. The main goal of cluster headache preventive therapy should be to make a patient cluster-free on preventives even though they are still in a cluster cycle. As most cluster headache patients have episodic cluster headaches, medications are only utilized while a patient is in cycle and is stopped during remission periods.
Abortive Therapy
The goal of abortive therapy for cluster headache is fast, effective, and consistent relief. A sumatriptan injectable can normally alleviate a cluster headache attack within 15 minutes.There is no role for over-the-counter (OTC) agents or butalbital-containing compounds in cluster headache and little if any need for opiates (see Table 1).
Table 2:Transitional Treatment Options
DHE = dihydroergotamine; IM = intramuscular.
DHE = dihydroergotamine; IM = intramuscular.
References:
- Klapper J A, Klapper A,Voss T,“The misdiagnosis of cluster headache: a nonclinic, population-based, Internet survey”, Headache (2000);40: pp. 730–735.
- Vingen J V, Pareja J A, Sovner L J,“Quantitative evaluation of photophobia and phonophobia in cluster headache”, Cephalalgia (1998);18: pp. 250–256.
- Nappi G, Micieli G, Cavallini A et al.,“Accompanying symptoms of cluster headache: their relevance to the diagnostic criteria”, Cephalagia (1992);3: pp. 165–168.
- Kudrow L,“Cluster headache: diagnosis and management”, Headache (1979);19: pp. 142–150.
- Ekbom K,“Treatment of acute cluster headache with sumatriptan”, N. Eng. J. Med. (1991);325: pp. 322–326.
- Ekbom K, Krabbe A, Micieli G et al., “Cluster headache attacks treated for up to three months with subcutaneous sumatriptan (6mg) (Sumatriptan Long-Term Study Group)”, Cephalalgia (1995);15: pp. 230–236.
- van Vliet J A, Bahra A, Martin V, “Intranasal sumatriptan is effective in the treatment of acute cluster headache-a double-blind placebo-controlled crossover study”, Cephalagia (2001);21: pp. 267–272.
- Hering-Hanit R, “Alteration in nature of cluster headache during subcutaneous administration of sumatriptan”, Headache (2000);40: pp. 41–44.
- Kudrow L,“Response of cluster headache attacks to oxygen inhalation”, Headache (1981);21: pp. 1–4.
- Rozen T D, Niknam R, Shechter A L et al., “Gender differences in clinical characteristics and treatment response in cluster headache patients”, Cephalalgia (1999);19: p. 323.
- Rozen,“High oxygen flow rates for cluster headache”, Neurology (2004);63: p. 593.
- Disabato F, Fusco B M, Pelaia P, Giacovazzo M,“Hyperbaric oxygen therapy in cluster headache”, Pain (1993);52: p. 245.
- Ekbom K, Hardebo J E, “Cluster headache: aetiology, diagnosis and management”, Drugs (2002);62: pp. 61–69.
- Leone M, D’Amico D, Attanasio A et al.,“Verapamil is an effective prophylactic for cluster headache: results of a double blind multicenter study versus placebo”, in Cluster: Headache and Related Conditions, Olesen J, Goadsby P J (eds), Oxford University Press (1999); pp. 296–299.
- Bussone G, Leone M, Peccarisi C, “Double blind comparison of lithium and verapamil in cluster headache prophylaxis”, Headache (1990),30: pp. 411–417.
- Steiner T J, Hering R, Couturier E G et al., “Double-blind placebo-controlled trial of lithium in episodic cluster headache”, Cephalagia (1997);17: pp. 673–675.
- Freitag F G, Diamond S, Diamond M L et al.,“Divalproex sodium in the preventative treatment of cluster headache”, Headache (2000);40: p. 408.
- El Amrani M, Massiou H, Bousser M G, “A negative trial of sodium valproate in cluster headache: methodological issues”, Cephalalgia (2002);22: pp. 205–208.
- Lainez M J, Pascual J, Pascual A M et al.,“Topiramate in the prophylactic treatment of cluster headache”, Headache (2003);43: pp. 784–789.
- Leone M, Damico D, Moschiano F, et al., “Melatonin versus placebo in the prophylaxis of cluster headache: a double blind pilot study with parallel groups”, Cephalalgia (1996);16: pp. 494–496. V21. Peres M F, Rozen T D, “Melatonin in the preventive treatment of chronic cluster headache”, Cephalalgia (2001);21: pp. 993–995.
- Pringsheim T, Magnoux E, Dobson C F et al., “Melatonin as adjunctive therapy in the prophylaxis of cluster headache: a pilot study”, Headache (2002);42: pp. 787–792.
- Leone M, Franzini A, Broggi G, Bussone G,“Hypothalamic deep brain stimulation for intractable chronic cluster headache: a 3- year follow-up”, Neurol. Sci. (2003);24 suppl. 2:S143–145.
- May A, Bahra A, Buchel C et al., “Hypothalamic activation in cluster headache attacks”, Lancet (2001);352: pp. 275–278.
