Cluster headache, rapid onset intense paroxysmal one-sided retro-orbital, supraorbital, and temporal pain lasting 15 to 180 minutes when untreated. The headaches often occur at night, waking the patient from a sound sleep with severe pain. With a cluster headache, the patients are very agitated during the attack (pacing and head pounding) and have no pre-headache aura and usually no associated nausea or vomiting. In Cluster HA, the afflicted are mostly men (5-6 x > than women), mostly smokers, and have an age of onset between 20 and 40 years old. Cluster HA patients must exhibit on the affected side one of the following autonomic signs [called Horner’s syndrome]: conjunctival injection, ptosis, miosis, eyelid edema, flushing, or blanching of the face, forehead or nasal sweating, lacrimation, nasal congestion, and rhinorrhea. The cluster HA’s occur in clusters and will often repeat several times in a 24-hour period (1 attack every other day to as many as 8 per day). The cluster period frequently lasts for weeks to months and is usually present in specific seasons of the year (> in winter & spring seasons) and can go into remission for months.
Cluster HA have a 3:1 male predilection, vs SUNCT which is 8:1. Duration of Cluster HA are 15-180mins. Frequency 1-8/day following Circadian Rhythm. Preventive tx: Ca channel blocker. Acute treatment: O2, Triptans, Ergots
Cluster headache is a form of headache that produces extreme pain and tends to occur in clusters, often at the same time(s) of the day, for several weeks to months. The headaches are accompanied by symptoms that may include bloodshot eyes, excessive tearing of the eyes, drooping of the eyelids (ptosis), runny nose and/or nasal congestion and facial sweating. Some people experience restlessness and agitation. Cluster headache attacks may strike several times a day, generally lasting between 15 minutes and three hours.
Traveling to a high altitude may trigger the onset of cluster headache. A change in altitude can affect cerebral blood flow.
Cluster Headache Medications
Medication | Dose range | Labs / monitor | Side effects |
Abortive | |||
Oxygen | |||
Sumatriptan SC or Nasal |
Nasal: 5mg or 20mg sprayed in the ipsilateral nostril at onset of the headache; may repeat once after 2 hours; onset 10-15 min
SQ: 3/4/6 mg SC; max is 6 mg/dose up to 12 mg ove 24 hrs, may repeat dose once; onset 10 min
|
Caution with patients with CV disease and HTN and patients taking antidepressants (serotonin syndrome)
Short acting esp nasal and SQ form |
may initially cause flushing, dizziness, weakness, nausea, drowsiness, stiffness, or feelings of tingling, heat, fatigue
|
2% lidocaine Nasal mist spray | |||
SPG block, evidence that this is diagnostic Occipital Corticosteroid injection |
20 to 40 mg of steroid | Local site reaction, systemic corticosteroid effects | |
Chronic | |||
Prednisone
|
20 to 40 mg/d for 3 to 6 days, then taper off over 4 to 8 days Have seen different dosages?? |
Many adverse effects. When used short term, insomnia, GI upset and anxiety. Serious adverse events have occurred even with short term | |
Verapamil |
240mg/d or bid- max dose 480mg/d | Constipation, ECG | Constipation, ECG should be performed b/c of possible cardiac abnormalities when higher doses are used. |
Topiramate |
Start 15-25 mg/hs; increase to max of 200mg/day in divided doses
25 mg tablets take 1 tablet at night Day 7: take 1 in the AM and 1 in the PM Day 14: take 1 in the AM, 2 in the PM Day 21: take 2 in the AM, 2 in the PM MAX: 200 mg If symptoms stop with any prophylactic meds u can stop them but u may not be able to |
Monitor bicarb levels b/c it can lower them
Migraine preventative |
Side effects: cognitive difficulties, sedation, fatigue, kidney stones, weight loss
Can cause acute glaucoma (IF THIS HAPPENS STOP THE MED!) |
Valproate |
250mg 2xday; 500-1500mg/day | Blood and Liver function tests | This is better tolerated than Valproic Acid, Birth defects, liver dysfunction, pancreatitis, dizzy night headed, vision change, loss of memory, weight gain, fatigue, GI upset |
Galcanezumab |
Loading dose 240 mg SC; followed by monthly injections of 120 mg SC
For episodic cluster prevention: 300 mg SC (3 injections) every 30 days while having an active cluster cycle |
Only preventative |
Side effects: constipation, injection site Warning: HTN (more pronounced in erenumab)
Not recommended in pregnant patients (must have 6 months free of antibodies before getting pregnant) |
Verapamil- (Ca channel blocker) Very effective in episodic and chronic cluster HA. Often initiated at the onset of HA, in conjunction with prednisone. Verapamil is then continued while the prednisone is tapered and then stopped. Because of its efficacy and minimal side effects, verapamil is a mainstay of cluster HA prevention.
Lambru, G., & Matharu, M. S. (2012). Trigeminal autonomic cephalalgias: A review of recent diagnostic, therapeutic and pathophysiological developments. Annals of Indian Academy of Neurology, 15(Suppl 1), S51–S61. https://doi.org/10.4103/0972-2327.100007