Cluster Headache

THE CLINICAL SYNDROME

Cluster headache derives its name from the pattern by which cluster headaches occur, namely, the headaches occur in clusters followed by headache-free remission periods. Unlike other common headaches disorders that affect primarily females, cluster headache happens much more commonly in males at a ratio of 5:1. Much less common than tension-type headache or migraine headache, cluster headache is thought to affect approximately 0.5% of the male population. Cluster headache is most often confused with migraine by clinicians unfamiliar with the headache syndrome. A careful, targeted headache history will allow the clinician to easily distinguish these two distinct headache types.

Horner's syndrome may be present during acute attacks of cluster headache.

The onset of cluster headache occurs in the late third or early fourth decade of life, in contradistinction to migraine, which almost always manifests itself by the early second decade. Unlike migraine, cluster headache does not appear to run in families and cluster headache will generally occur approximately 90 minutes after the patient falls asleep. This association with sleep is reportedly maintained when a shift worker changes to and from nighttime to daytime hours of sleep. Cluster headache also appears to follow a distinct chronological pattern that coincides with the seasonal change in the length of day. This results in an increased frequency of cluster headaches in the spring and fall.

During a cluster period, attacks occur two or three times a day and last for 45minutes to 1 hour. Cluster periods usually lat for 8 to 12 weeks, interrupted by remission periods of less than 2 years. In rare patients, the remission periods become shorter and shorter and frequency may increase up to 10-fold. This situation is termed chronic cluster headache and differs from the more common episodic cluster headache described earlier.

SIGNS AND SYMPTOMS

Cluster headache is characterized as a unilateral headache that is retro-orbital and temporal in location. The pain has a deep burning or boring quality. Physical findings during an attack of cluster headache may include Horner’s syndrome, consisting of ptosis, abnormal pupil construction, facial flushing, and conjunctival injection. Additionally, profuse lacrimation and rhinorrhea are often present. The ocular changes may become permanent with repeated attacks. Peau d’orange skin over the malar region, deeply furrowed and glabellar folds, and telangiectasia may be observed (Fig. 4-1).

Attacks of cluster headache may be provoked by small amounts of alcohol, nitrates, histamines, and other vasoactive substances and occasionally by high altitude. When the attack is in progress, the patient may not be able to lie still and may pace or rock back and forth in a chair. This behavior contrasts with that characterizing other headache syndromes, during which patients seeking relief will lie down in a dark, quiet room.

The pain of cluster headache is said to be among the worst pain from which mankind suffers. Because of the severity of pain associated with cluster headaches, the clinician must watch closely for medication overuse or misuse. Suicides have been associated with prolonged, unrelieved attacks of cluster headaches.

TREATMENT

In contradistinction to migraine headache, in which most patients experience improvement with the implementation of therapy with B-blockers, patients suffering from cluster headache will usually require more individualized therapy. A reasonable starting place in the treatment of cluster headache is to begin treatment with prednisone combined with daily sphenopalatine ganglion blocks with local anesthetic. A reasonable starting dose of prednisone would be 80 mg given in divided doses tapered by 10mg per dose per day. If headaches are not rapidly brought under control, inhalation of 100% oxygen via close fitting mask is added.

If headaches persist and the diagnosis of cluster headache is not in question, a trial of lithium carbonate may be considered. It should be noted that the therapeutic window of lithium carbonate is small and this drug should be used with caution. A starting dose of 300 mg at bedtime may be increased after 48 hours to 300 mg twice a day. If no side effects are noted, after 48 hours the dose may again be increased to 300 mg three times a day. The patient should be continued at this dosage level for a total of 10 days, and the drug should then be tapered downward over a 1-week period.; Other medications that can be considered if these treatments are ineffective include methysergide and sumatriptan and sumatriptan-like drugs.

In rare patients suffering from cluster headaches, the aforementioned treatments are ineffective. In this setting, given the severity of pain and the risk of suicide, more aggressive treatment is indicated. Destruction of the gassarian ganglion either by injection of glycerol or by radiofrequency lesioning may be a reasonable next step.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue .Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.