|
| |
| Cluster Headache ( a form of
Trigeminal Autonomic Cephalagias) |
 | Male:female ratio 4:1 to 20:1 |
| Most common in third decade |
| Forms:
 | Episodic: 80% of patients
 | Initial series last 6 to 12 weeks |
| Pain free periods may last months or years |
| 10% becomes chronic, have attacks for years |
|
| Chronic form: 20% of patients. occurring for
more than 1 year. |
|
| Variants:
| Chronic paroxysmal hemicrania: (Sjaastad
& Dale) attacks more frequent, last shorter, respond to
Indocin. |
| Cluster headache variant: (Medina &
Diamond) multiple jabs with background vascular headache
without headache free interval. |
|
|
| THE INDIVIDUAL ATTACKS |
| Unilateral, maximal in temporal & orbital region |
| Severe, lasts 15 minutes to 3 hours |
| Described as boring, burning, excruciating, steady, nonthrobbing |
| Begins without warning, reaches peak in a few minutes |
| May have 4 to 6 attacks per day |
| Nocturnal attacks more common, disrupt sleep |
| Autonomic symptoms: ipsilateral facial sweating, & flushing, tearing, blockage of
nose |
| Patient prefers to pace or sit |
| Heavy use of alcohol or tobacco common |
| Most will continue to work |
| Narcotic or medication abuse & dependency is rare |
|
| TREATMENT: SYMPTOMATIC |
| O2 6-8L/min, loose face mask, effective 60-80% |
| Sumatriptan: 6 mg sc, may repeat once in 1 hour.
Maximal 2 shot per 24 hour period. Triptan
table |
| Ergotamine 1-2 mg orally or suppository, or nasal spray |
| Dihydroegotamine (DHE 45) 0.5 to 1.5 mg IV, IM or SC.
Usually given with metoclopramide or other emetic. |
| Narcotic, not effective |
|
| TREATMENT: PROPHYLACTIC |
| Prednisone 60mg/day taper over 2-3 weeks |
| Verapamil 240 - 480 mg, may take 2-3 weeks to work |
| Lithium 300 to 1200 mg per day in divided dose, for chronic Cluster headache.
Probably effective at a lower level than required in bipolar
disorder (0.3-0.8 mmol/L). |
| Valproate (Depakote) 750 - 1500 mg/d, effective in episodic form |
| Methysergide (Sansert) 2 to 8 mg per day in
divided dose. Maximum 4 to 6 months, need 1 month drug holiday to
avoid fibrotic complications.
| 11/19/2002 Norvartis:
Product is discontinued but remaining supply which expires February
2003 may be ordered by calling Novartis at (888)669-6682. |
|
| Ergotamine 1-2mg/d |
|
| Surgical Treatment
for the truly intractable |
| Radiofrequency gangliorhizolysis: abolish the function of the Ophthalmic and
maxillary divisions of the Trigeminal nerve |
| Loss of corneal reflex |
|
| Further Reading |
|
|
| Differentiate |
Cluster |
Migraine |
| Sex |
predominantly male |
female |
| Age of onset |
20 to 40 |
15 to 20 |
| Frequency of attacks |
several attacks daily |
1 to 4 a month |
| Unilaterality |
unilateral |
unilateral or bilateral |
| Nausea & vomiting |
rare |
common |
| Behavior during attack |
pace or sit |
prefers rest & quiet |
| Comparison
of different types of Trigeminal Autonomic Cephalalgias |
| |
Cluster headache |
Paroxysmal hemicranial |
SUNCT syndrome |
| Sex ratio F:M |
1:4 |
2:1 |
1:2 |
| Pain character |
stabbing, boring |
throbbing, boring, stabbing |
burning, stabbing |
| Pain location |
Orbit, temple |
Orbit, temple |
Periorbital |
| Frequency of attack |
1 qod to 8/day |
1-40/day |
1/d to 30/hour |
| Duration of attack |
15-180 min |
2-45 min |
5-250 sec |
| Migraine feature: nausea,
photophobia, phonophobia |
Yes |
Yes |
No |
| Triggered by alcohol |
Yes |
Occasional |
No |
| Abortive treatment |
Triptan injection or NS,
oxygen |
none |
none |
| Preventive Rx |
Verapamil, Methysergid,
Lithium, Prednisone |
Indomethacin |
Lamotrigine, Topiramate,
Gabapentin |
|
