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Current Status of Cluster Headaches

Current Status of Cluster Headaches

By Lawrence E. Lamb, MD



The pain is one of the worst a person can endure. It usually causes a knifelike pain behind the eye and quickly spreads to the forehead and the same side of the nose. The pain can spread to the neck on the same side, the back of the skull and even into the teeth. The nose often runs and the in­volved eye tears. The eyelid may droop, and the pupil of the eye be­comes smaller. The pain can be so intense that patients may even con­template suicide.

_ Such headaches are called cluster headaches because they occur in clus­ters. During the phase of cluster head­aches, at least one attack occurs each day, and sometimes there are many attacks daily. The attacks begin sud­denly and may last a few minutes or, more commonly, 30 minutes to two hours. The cluster may last a few weeks or a couple of months. In some instances, a chronic form occurs, but this is even more rare.

The most distinguishing feature is the timing of recurrent attacks. The daily attacks usually occur with almost clocklike regularity. If you have an attack at 3 a.m., you can expect other attacks at the same time. In fact, 50-75% occur at night. Cluster headaches tend to occur in the spring and fall, just before and after the longest and shortest days. There does seem to be some relation to the day-night cycle and its length with different seasons. Men are much more prone to cluster headaches than women. The ratio of men to women who suffer from cluster headaches is 5 to 1.

What causes cluster headaches? No one knows, but they do appear to be related to arterial constriction and dilatation. At one time they were considered as a variant of migraine headaches. Sleep studies suggest they are triggered by changes in the level of oxygen in the blood.


What can be done for people who suffer from cluster headaches? There are many treatments that have been proposed. Some of the treat­ments provide relief from the immediate attack, and others help prevent the recurrent attacks that occur once the clusters begin.

Oxygen Inhalation is used to abort an acute attack and is re­ported to provide relief in 60-80% of cases if it is administered at the very beginning of the attack Unfortunately, the headache may quickly return.

Ergotamine tartrate (Ergostat), a medication causing con­ striction of arteries, is often used. It may be placed under the tongue and is reported to be effective in 50-85% of cases. An injectable form is often used in the emergency room, and lots of these patients do end up in the emer­gency room with their severe attacks. The ergotamine products may also have some effects on brain chemicals (serotonin receptors) as well.

Xylocalne, a topical anesthetic, has been used as a 4% solution and instilled well back into the nose, with the head tilted backward and down­ward so the drops reach high into the nasal passages. The pain of cluster headaches is transmitted through a mechanism involving the fifth cranial nerve, the trigeminal nerve, that sup­plies the area where the pain occurs. It is believed that the anesthetic affects a reflex through this nerve to abort an attack Despite some original enthusi­asm, it has not been as effective as hoped.

Cocaine, as an anesthetic, has also been used, but there is a serious danger of addiction.

Sumatriptan (Imitrex), a new drug, has been used with great success in Europe in aborting mi­graine headaches and has recently been reported to be effective in treat­ing acute attacks. Nearly half of the patients who received an injection were pain-free within 15 minutes.

Attacks may also be prevented by taking ergotamine until there have been no more attacks for at least two weeks. If the attacks occur only at night, the medication can be used only before going to bed. Other medi­cines that have been reported to be helpful in preventing attacks include lithium carbonate, the calcium channel blockers, such as Calan (ye­rapamil), or Procardia. Prednisone has also been used, but attacks may recur as the dosage is decreased. Valproic acid (Depakene, Depakote) appears to be an effective preventive in as many as 60% of patients.

It is important to know that during a cluster of attacks, a person must not use any alcohol, because that can cause an attack. 

When all else fails and the headaches persist, radio frequency waves may be used for thermocoagulation of an area (ganglion) of the trigemi­nal nerve in selected patients. Almost all of these treatment approaches have the potential of side effects and require considerable skill in using them in a cluster-headache victim. But there are now many approaches to this difficult problem.  

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