Cluster Headache - Diagnosis and Treatment

Cluster Headache - Diagnosis and Treatment

Todd D Rozen
US Neurology Review 2005
Published: October 2008
download article

| More
dots

Valproic Acid
In a open label investigation 26 patients (21 chronic cluster, five episodic cluster) were treated with divalproex sodium.17 The mean decrease in headache frequency was 53.9% for the chronic cluster patients and 58.6% for the episodic cluster patients. The mean dose of divalproex sodium used was 838mg, which could be considered a low dose by cluster standards. Recently, a double-blind placebo controlled study of sodium valproate (1,000–2,000mg/day) in cluster was completed. Ninety-six patients were included, 50 in the sodium valproate group and 46 in the placebo group. After a seven-day run-in period, patients were treated for two weeks. Primary efficacy was the percentage of patients having an at least 50% reduction in the average number of attacks per week between the run-in period and the last week of treatment. Fifty per cent of subjects in the sodium valproate group and 62% in the placebo group had significant improvement (P=0.23). Due to the high success rate seen with the placebo, the authors felt they could make no conclusion about the efficacy of sodium valproate in cluster.18 The extended release preparation of valproic acid appears to work well and dosing up to 3,000mg qhs can be effective.

Topiramate
Topiramate is a more recent antiepileptic that may be efficacious in both migraine and cluster headache prevention. Lainez et al.19 treated 26 patients (12 episodic, 14 chronic) with topiramate to a maximum dose of 200mg. Topiramate rapidly induced cluster remission in 15 patients, reduced the number of attacks by more than 50% in six patients, and reduced the cluster period duration in 12. The mean time to remission was 14 days, but in seven patients remission was obtained within the first days of treatment with very low dosages (25–75mg a day). Six patients discontinued treatment due to side effects (all with daily dosages over 100mg) or lack of efficacy.

Topiramate should be initiated at a dose of 25mg per day and increased in 25mg increments every five days up to 75mg.The patient should be monitored at this dose for several weeks before deciding if the dose needs to be increased. Dosages up to 400mg have been needed in some cluster patients. Anecdotally, there appears to be a therapeutic window for topiramate in cluster. Some patients have experienced worsening of attacks when the dose is raised above a certain limit and improvement again when the dose is lowered back down.

Melatonin
Serum melatonin levels are reduced in patients with cluster headache, particularly during a cluster period. This loss of melatonin may be the inciting event necessary to at least produce nocturnal cluster attacks. Providing back melatonin via an oral supplementation route theoretically could act as a cluster preventive. The efficacy of 10mg of oral melatonin was evaluated in a double-blind, placebocontrolled trial.20 Cluster headache remission within three to five days occurred in five of 10 patients who received melatonin compared with zero of 10 patients who received placebo. Melatonin only appeared to work in episodic cluster patients. Recently,melatonin has also been shown to be an effective preventive in chronic cluster headache.21 A negative study was published utilizing melatonin for cluster prevention but the dosing was lower than the other studies and a sustained preparation was given.22 The author believes that melatonin should be initiated in all cluster patients as a first-line preventive sometimes even before verapamil. It has minimal side effects and in a number of patients it can turn off nocturnal clusters within 24 hours. Melatonin also appears to prevent daytime attacks. In addition, even when melatonin does not completely resolve all of the attacks it appears to lower the dose necessary of the other addon preventives. The typical dose of melatonin used is 9mg at bedtime (three 3mg tablets) but higher dosages may be necessary. If one brand of commercial melatonin does not work another should be tried because the true amount of melatonin in various OTC brands varies widely.

Surgical Treatment of Cluster Headache
The surgical treatment of cluster headache should only be considered after a patient has exhausted all medicinal options or when a patient’s medical history precludes the use of typical cluster abortive and preventive medications. Episodic cluster patients should rarely be referred for surgery because of the presence of remission periods. Once a cluster patient is deemed a medical failure only those who have strictly side-fixed headaches should be considered for surgery. Other criteria for cluster surgery include pain mainly localizing to the ophthalmic division of the trigeminal nerve, a psychologically stable individual and one without an addicting personality. Cluster patients must understand that, in most instances, to alleviate their cluster pain, the trigeminal nerve will have to be injured, leaving them not only with facial analgesia but a risk of developing severe adverse events including corneal anesthesia and anesthesia dolorosa.

« first‹ previous123456next ›last »
References:
  1. Klapper J A, Klapper A,Voss T,“The misdiagnosis of cluster headache: a nonclinic, population-based, Internet survey”, Headache (2000);40: pp. 730–735.
  2. Vingen J V, Pareja J A, Sovner L J,“Quantitative evaluation of photophobia and phonophobia in cluster headache”, Cephalalgia (1998);18: pp. 250–256.
  3. 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.
  4. Kudrow L,“Cluster headache: diagnosis and management”, Headache (1979);19: pp. 142–150.
  5. Ekbom K,“Treatment of acute cluster headache with sumatriptan”, N. Eng. J. Med. (1991);325: pp. 322–326.
  6. 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.
  7. 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.
  8. Hering-Hanit R, “Alteration in nature of cluster headache during subcutaneous administration of sumatriptan”, Headache (2000);40: pp. 41–44.
  9. Kudrow L,“Response of cluster headache attacks to oxygen inhalation”, Headache (1981);21: pp. 1–4.
  10. 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.
  11. Rozen,“High oxygen flow rates for cluster headache”, Neurology (2004);63: p. 593.
  12. Disabato F, Fusco B M, Pelaia P, Giacovazzo M,“Hyperbaric oxygen therapy in cluster headache”, Pain (1993);52: p. 245.
  13. Ekbom K, Hardebo J E, “Cluster headache: aetiology, diagnosis and management”, Drugs (2002);62: pp. 61–69.
  14. 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.
  15. Bussone G, Leone M, Peccarisi C, “Double blind comparison of lithium and verapamil in cluster headache prophylaxis”, Headache (1990),30: pp. 411–417.
  16. 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.
  17. Freitag F G, Diamond S, Diamond M L et al.,“Divalproex sodium in the preventative treatment of cluster headache”, Headache (2000);40: p. 408.
  18. 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.
  19. Lainez M J, Pascual J, Pascual A M et al.,“Topiramate in the prophylactic treatment of cluster headache”, Headache (2003);43: pp. 784–789.
  20. 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.
  21. 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.
  22. 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.
  23. May A, Bahra A, Buchel C et al., “Hypothalamic activation in cluster headache attacks”, Lancet (2001);352: pp. 275–278.

Copyright® 2004 - 2010 Business Briefings, Ltd. All rights reserved.
Touch Neurology is for informational purposes and should not be considered medical advice, diagnosis or treatement recommendations.