Podcast #242 - 10 Key Pearls for Cluster Headaches

Cluster headaches are often considered one of the most painful human experiences.  They are short (lasting usually 15-180 minutes), frequent (up to 8 a day), unilateral headaches behind or around the eye often with ipsilateral autonomic symptoms and restlessness.  While migraines and tension headaches are seen frequently in the emergency department, cluster headaches are much less frequently seen and often are harder to identify as a result.  There are certain points to remember with patients that are experiencing cluster headaches and we list 10 of them here.

These pearls come from a recent BMJ article title Recent Advances in the Diagnosis and Management of Cluster Headache by Emmanuelle Schindler and Mark Burish. 

1. Suicidal ideation (SI) occurs in 55-64% of patients and self-injurious behavior is often seen.
2. Cluster headaches are associated with smoking, but cessation does not alter the disease.
3. There are episodic and chronic types:
   1. Episodic occurs only during a period of weeks to months often in an annual cycle and accounts for approximately 80% of cases.
   2. Chronic accounts for the other approximately 20% and occurs throughout the year without remission.
4.  There are certain clinical features that can help distinguish and identify cluster headaches:
   1. Preattack "shadows" with symptoms present shortly prior to the actual attack (ipsilateral aching, lacrimation, and nasal congestion often seen minutes before) and further out (such as an hour) there are generalized symptoms including difficulty concentrating and mood changes.
   2. Mild symptoms may remain between these attacks.
   3. There is often restlessness which helps differentiate it from migraines.
   4. Self injurious behaviors are often seen (but unrelated to SI) such as hitting or rubbing head, punching walls, and cutting or piercing skin.
   5. Dysautonomia is also seen where there are changes in autonomic tone including bradycardia, altered tilt table testing, and nocturnal lipolysis.
5. Approximately 80% of patients can predict when attacks occur (often around 2-3 AM), have an annual rhythm (often less common in summer months), and daylight hours are associated in general with fewer attacks.
6. There are common triggers (chemical, environmental, and physiologic) that are often noted, but it may not have effect outside of the attack cycle:
   1. The most common chemical trigger is alcohol (EtOH) which usually occurs within an hour, nitroglycerin, PDE5 inhibitors, and strong smells (such as cleaners or perfumes).
   2. Environmental triggers often include high altitude, weather changes, or bright sunlight.
   3. Physiologic triggers include sleep, circadian rhythm disruption (such as shift work, jet lag, and time changes), stress, relaxation, menstruation, menopause, postpartum, and low testosterone. 
7. Brain MRI can help rule out secondary causes and if refractory consider other testing such as MRA of the head and neck, pituitary lab tests, sleep study for obstructive sleep apnea, and if Horner syndrome is present image the lung apex.
8. Acute treatment includes sumatriptan, oxygen (often 6-12 L/min), and noninvasive vagus nerve stimulation.
9. Transitional treatments include steroids (including occipital nerve injection) and dihydroergotamine.
10. Preventative treatments include a variety of medications that can be used if chronic cases or before typical period of episodes which includes verapamil, lithium, melatonin, capsicum, topiramate, baclofen, and galcanezumab. 

You can learn more by clicking on the link above or downloading the PDF listed below.

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Podcast #242
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Recent Advances in the Diagnosis and Management of Cluster Headache
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