treating Cluster headache with surgery and chemical medication

Cluster headache is pain that occurs along one side of the head. It's frequently described as pain that occurs around, behind, or above the eye and along the temple in cyclic patterns or clusters. The pain of a cluster headache is very severe. Many patients describe a “drilling” type of sensation. For classification as a true cluster headache, associated autonomic features such as tearing/watering of the eye, redness of the conjunctiva, rhinorrhea or nasal stuffiness, eyelid drooping, sweating on one side of the face, or changes in pupil size (with the pupil on the affected side becoming notably smaller) are usually present. The headache lasts from 15 minutes to a maximum duration of about 3 hours. However, the headache can recur up to eight times daily.

Cluster headache

The specific cause and anatomic origination of cluster headaches isn't known. MRI studies suggest dilation of the ophthalmic artery during an acute cluster headache, while PET scans reveal activity within the cavernous sinus. However, many patients with other headache types also have revealed abnormalities in similar regions, so these tests aren't definitive. There is some evidence that the hypothalamus may be involved in the recurrence cycle of cluster headaches. Activation of the trigeminal ganglion can cause many changes associated with cluster headache, but the trigger for activation of this region hasn't been identified.

Who gets this kind of headaches?

Males are two to four times more likely to develop cluster headache than females; however, the overall frequency is quite low, with a prevalence rate of about 1 per 1,000. Because of the rarity of the condition, limited information is available.

Although the vast majority of patients are adults, cluster headache has been reported in children as young as 6 years of age.

What are the symptoms and signs of Cluster migraine?

 Cluster headache is always unilateral, or one-sided. However, some patients may experience some variability of the side on which their headache occurs. Most patients describe their pain as occurring around or behind the eye. Pain is also described as radiating along the forehead, into the jaw or along the gum line and into the teeth, or across the cheek of the affected side. Infrequently, pain may extend into the ear, neck, or shoulder. Although watering (tearing) of the eye is frequently identified, some patients may only experience some redness of the conjunctiva. Eyelid drooping or swelling and a runny nose (rhinorrhea) are often associated with the pain of a cluster headache. Symptoms more commonly identified with migraine headaches, including sensitivity to light, sounds, or odors may occur. However, unlike migraine headache, movement does not worsen the pain of a cluster headache. In fact, many patients describe a sense of restlessness during their pain.

The headaches associated with cluster occur in groups. While the headaches themselves may be brief (as short as 15 minutes), the headaches can recur up to eight times in 24 hours. Headaches may last as long as 3 hours. Cluster cycles may last for only a single day, or may linger for many weeks.

diagnosis options

The diagnosis of cluster headache is typically made after the history of headaches has been explored and a physical examination is completed. Cluster headaches are unique in their presentation, and often the history is sufficient to make the diagnosis. While no imaging study or specific blood test can confirm the diagnosis of cluster headache, an MRI or CT scan of the brain may be ordered to confirm that there are no other contributing factors that may mimic cluster headache symptoms. In some cases, ophthalmologic evaluation is needed to exclude problems within the eye itself that may be causing symptoms.

treatment options 

There are various ways to treat this type of headache including :

Abortive treatments

Inhalation of high-flow, concentrated oxygen is extremely effective in stopping a cluster headache attack and is the treatment of choice. Although oxygen is readily available in emergency departments, its widespread use in the home setting is limited by safety concerns and other reasons.

An occipital nerve steroid injection of methylprednisolone acetate (Depo-Medrol) may stop a cluster headache attack.

The following are abortive drugs in the triptan class. They are used to stop cluster headache attacks in progress, but they have little preventive value.

• Sumatriptan (Imitrex)
• Naratriptan (Amerge, Naramig)
• Zolmitriptan (Zomig, Zomig-ZMT)
• Rizatriptan (Maxalt, Maxalt-MLT)
• Almotriptan (Axert)
• Frovatriptan (Frova)
• Eletriptan (Relpax)

The following nontriptans are also used to stop attacks. They are sometimes effective when triptans fail.

• Ergotamine (Cafatine, Cafergot, Cafetrate, Ercaf)
• Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)
• Acetaminophen-isometheptene-dichloralphenazone (Midrin)
• Intranasal lidocaine (4%)
• Intranasal capsaicin
• Prednisone (Deltasone) - Too toxic for long-term use but should be tried if other therapies fail

Preventive treatments

People who have frequent cluster headache attacks and report that the attacks affect quality of life should use preventive therapy as the main element of their treatment plan. Specific headache-stopping drugs (abortive treatments) may also be taken as necessary.

The goals of preventive therapy include decreasing the frequency and severity of acute attacks and improving quality of life.

The choice of preventive medication should be tailored to the individual's profile, taking into account comorbidities (concurrent medical conditions) such as depression, weight gain issues, exercise tolerance, asthma, and pregnancy plans. All medications have side effects; therefore, selection must be individualized.Preventive drugs include beta-blockers, tricyclic antidepressants, some anticonvulsants, calcium channel blockers, cyproheptadine (Periactin), and nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn). Unlike the specific headache-stopping drugs (abortive drugs), most of these were developed for other conditions and have been coincidentally found to have headache preventive effects. The following drugs also have preventive effects; unfortunately, they also have more side effects:

• Methysergide (Sansert)
• Verapamil(Calan, Verelan, Covera-HS)
• Lithiumcarbonate (Eskalith, Lithane, Lithobid, Lithonate, Lithotabs)
• Indomethacin(Indocin): This drug can cause psychosis in some people with cluster headaches.

Surgery

Some surgical operations have been successful in treating people whose cluster headaches do not respond to standard drug treatments. These procedures include nerve blocks and ablative neurosurgical procedures (operations that involve the removal or destruction of a part of the brain, the spinal cord, or a nerve). Radiosurgery (a type of surgery that uses radiant energy and does not involve cutting) has recently been used to provide a less invasive alternative for people who have persistent cluster headaches.

What triggers cluster headaches?

 Many patients report their headaches begin while sleeping. Additionally, alcohol can trigger cluster headaches in patients who are in the midst of a cycle. Histamines and nitroglycerin can trigger cluster headaches in patients. Seasonal variation has been described, although this is inconsistent for many patients. Some patients have clusters precipitated by environmental changes or changes in stress or activity levels. Hormonal factors, or menstruation, do not seem to trigger cluster headache. Other risk factors include smoking and a family history of the problem.

Can cluster headaches be prevented?

Once cluster headaches have been accurately diagnosed, long-term treatment can be beneficial to decrease or prevent future cycles. However, as the specific underlying cause isn't known, it may take some time to control the headache cycles.

What is the prognosis for this headaches?

Over time, cluster headache seems to diminish in frequency, but this may take many years. Cluster headache can go into remission for an extended period of time and then recur. As such, discussion with your physician regarding need for continuation of treatment is warranted.

Cluster headache does not appear to be associated with other neurological illness, such as Alzheimer's dementia, Parkinson's disease, or multiple sclerosis (MS); however, many individuals with multiple sclerosis are known to experience severe headaches.