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Cluster Headache

Cluster headaches are unique in several ways. They occur in an episode—or cluster—that may occur daily over a period of weeks, sometimes even months. They may then disappear, only to recur seasonally the following year. In contrast with migraine, which is more common in women, cluster headaches occur mainly in men between the ages of 20 and 40. A person experiencing cluster headaches may have up to eight attacks per day, each lasting about 15 to 45 minutes or longer. Attacks often come in the early morning hours, and will waken the patient from sleep.

The pain of cluster headaches usually is centered around one eye, and is almost always on one side of the head. There can be nasal stuffiness and tearing with the headache. The pain is excruciating for most people, often described as a knife or nail being driven into the head. Unlike migraine headache, lying down often makes cluster headaches worse. Some people pace the floor and move about, unable to find any relief.

Causes

Precisely what causes cluster headaches is unknown, but the condition has several well-recognized triggers, including alcohol, particularly if a person is going through a cluster period, and nitroglycerine or similar drugs. The fact that some of these triggers also cause blood vessels to dilate or open up to increase blood flow, or involve medications which make blood vessels constrict or narrow to reduce blood flow, suggests that changes in the vascular structure of the head may be partly responsible. There are other causes of headache as well.

Brain Tumors
Many people with brain tumors have headaches. Their pain may be worse in the morning as a result of pressure buildup in the brain after lying flat all night. It usually increases with coughing or straining, and is often accompanied by nausea and vomiting. CT (computer tomography) scans or MRI (magnetic resonance imaging) scans can help differentiate between cluster headaches and those caused by brain tumors.

Infections
Meningitis, an infection of the coverings of the brain, or brain abscess, a collection of infected tissue in the brain, also can lead to headaches. Such patients may have a stiff neck, fever, abnormal laboratory test or neurological examination results. CT scans, MRIs or a spinal tap, a procedure in which cerebrospinal spinal fluid is drawn for examination, may be necessary for a differential diagnosis.

Other infections that can cause headaches are sinusitis (sinus infection), ear infections, dental disease and infections of the eye.

Cerebral Aneurysm
An aneurysm is a widening of a blood vessel wall that can rupture, leading to bleeding in the brain, known as subarachnoid hemorrhage. The pain this causes has often been described as the worst headache of one's life. CT scans and MRI scans are used to make a differential diagnosis. Other tests include angiography (procedure in which a catheter is threaded upward through successive arteries to the neck and brain, where a contrast dye is injected into the blood to facilitate x-ray images) and spinal tap, which can disclose the presence of blood in the cerebrospinal spinal fluid.

Temporal Arteritis
An inflammation of an artery, this disorder usually occurs in older persons, and is associated with headache, muscular and joint aches, weight loss, malaise, fever and sometimes jaw pain. Its most worrisome symptom is transient visual loss, which may lead to permanent blindness if the disorder goes undiagnosed.

Patients typically complain of tenderness when the scalp or sides of the head are touched. Laboratory studies may show an elevation of the patient's ESR (erythrocyte sedimentation or "sed" rate), indicating inflammation. Some patients with temporal arteritis also have low blood iron levels (anemia). Most patients with suspected temporal arteritis are sent for a biopsy, in which a surgeon removes a small piece of the inflamed artery for microscopic examination to ensure correct diagnosis. Treatment involves steroids, mainly prednisone, often for an extended period to control the inflammation and prevent blindness.

Trigeminal Neuralgia
This pain, also known as tic douloureux, involves the nerves of the face and usually occurs on one side of the face only. Its pain is intermittent and severe, often describes as electric shock-like or stabbing. Talking, eating, or even by something as seemingly innocuous as wind blowing against the cheeks may trigger pain. Where many attacks occur in a short period, the face may be sore constantly. People often lose weight and sleep from frequent attacks.

Trigeminal neuralgia is most common in people over 40. The disorder may have many causes. Multiple sclerosis, tumors and blood vessel abnormalities may be responsible for a few cases, but in most instances the cause remains obscure.

One of the more commonly prescribed drugs used to treat trigeminal neuralgia is carbamazepine (Tegretol, Carbatrol). Three-quarters of all patients respond favorably to its use. Other medications that may be beneficial include gabapentin (Neurontin), tramadol (Ultram) and phenytoin (Dilantin). Pain medications also may be necessary during prolonged attacks.

Treatment

Treating cluster headache involves addressing the severe, sometimes unbearable, pain during the headache, and disrupting or shortening the cluster episode. Acute treatment medications are similar to those used for migraine and include:

• Sumatriptan, which can be given in injectable or nasal form for rapid onset. The other oral triptans may also be effective.
• DHE(Migranal)—Delivered as a nasal spray, can have a rapid onset. DHE is also available in an injectable form. It is also useful in migraine. Side effects include nausea and dizziness.
• Narcotics may be helpful, although the onset of most oral agents may not be rapid enough, given the severity and brief duration of the headache.
• Breathing 100% oxygen during the acute headache can be helpful for some people. When the diagnosis of cluster is made, and other medications do not work well, a tank of oxygen can be kept for home use.

Prevention

Prednisilone(Prednisone)
This is a steroid medication that is taken initially in high doses, then tapered over days to weeks, depending on the response. This medication is best if used for short periods of time, as long term steroid use is associated with many complications.

Lithium carbonate
This medication is taken orally, usually twice a day in order to interrupt the cluster. Laboratory testing including lithium levels should be followed closely. Side effects include tremor, increased thirst and gastrointestinal symptoms.

Verapamil
This is a medication that can also be effective in migraine. It can be taken twice daily in a sustained oral preparation. Side effects include dizziness and constipation.

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