Friday, 11 April 2014

Cluster Headaches

Cluster headaches are severe unilateral headaches. They used to be called migranous neuralgia. They are short lasting and are accompanied by autonomic symptoms. Less than 1% of patients have cluster headache, and it affects men more than women (3- 6 times more), and young people (in their 30s) rather than old people. 85% of patients smoke. They present similarly in men and women, but women tend to have more migrainous type symptoms. Alcohol, nitroglycerine, exercise, and elevated environmental temperature are recognized precipitants of acute cluster attacks.

- Short bouts of pain, lasting weeks or months
- Bouts may occur up to eight times a day
- Follow a circadian rhythm, with a 24hour cycle
- One sided in the orbital, supraorbital or temporal regions
- Associated with autonomic symptoms (ptosis, miosis, eye watering, bloodshot eye, runny nose, blocked nose).
- Autonomic symptoms occur on the same side as the pain

Official Diagnosis
A diagnosis of cluster headache is supported by at least five attacks that fulfil the following criteria:
Severe pain on one side in the orbital, supraorbital, or temporal region which lasts 15 to 180 minutes if left untreated.
At least one of the following on the same side:
   Bloodshot or watery eye
   Blocked or runny nose
   Eyelid oedema
   Forehead and facial sweating
   Miosis or ptosis, or both
   A sense of restlessness or agitation
Attacks that occur every other day at a frequency of up to eight per day
Other causes have been excluded.

Migraine vs Cluster Headache

 Alcohol induces cluster headache quickly, migraines some hours after.

To manage patients with cluster headache you should treat the acute attack and consider prophylaxis against further attacks

- 100% via non re-breath mask for at least 20 minutes
- 60% of patients respond to oxygen therapy
- More beneficial at the onset of symptoms

- 6mg sc sumatriptan relieves pain in 20minutes in 75% of patients
- Oral triptans are too slow
- Triptans contraindicated with cardiovascular, cerebrovascular disease and untreated arterial hypertension. Do NOT use with MAOIs or ergotamines.
- Side effects include chest pain and distal paraesthesiae.

Oral ergotamine has been used to treat cluster headache for more than 50 years, but there is little evidence available to support its effectiveness.

Applying lidocaine nasally is effective in about one third of patients. The suggested dosage is 1 ml with a concentration of 4-10%, given on the same side as the pain. The patient should lie back with their head turned to the affected side after application. Most of these studies are small, and the effect is unlikely to be clinically beneficial.

Up to 80% of patients with cluster headache respond to steroids. Start with 60-100 mg of prednisolone once a day for at least five days. After this you should try to decrease the dosage by 10 mg every day.

Third Line Treatment
Pizotifen, valproic acid, topiramate and capsaicin. Prevent with verapamil or lithium.

Follow Up
It is recommended that patients attending with cluster headaches should be followed up in neurology outpatients for consideration of further imaging as there is a link with pituitary adenoma.

Paroxysmal hemicrania
Paroxysmal hemicrania is rare. It is similar to cluster headaches but patients have shorter, more frequent attacks. They have a good response to indomethacin. This is one of the diagnostic criteria. Within three to seven days of starting indomethacin at an adequate dosage the attacks disappear. The usual dose is 50 mg three times per day. It is worth trying a trial of indomethacin even if the headache is not typical of paroxysmal hemicrania; if patients are going to respond, they will do so quickly.

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