Diagnosis and Treatment of Cluster Headache

Abstract

Cluster headache is an uncommon yet distinctive neurovascular syndrome occurring in either episodic or chronic patterns. The most unique feature of cluster headache is the unmistakable circadian and circannual periodicity. The attacks are stereotypical, that is, of extreme intensity, of short duration, occurring unilaterally, and associated with robust signs and symptoms of autonomic dysfunction. Unlike migraine, during an attack the patient with cluster headache often paces about. Attacks frequently occur at night, awakening the patient from sleep. Although the pathophysiology of cluster headache remains to be fully elucidated, several seminal observations have recently been made. The medical treatment of cluster headache includes acute, transitional, and maintenance prophylaxis. Agents used for acute therapy include inhalation of oxygen and triptans, such as sumatriptan, and dihydroergotamine. Transitional prophylaxis refers to the short-term use of fast-acting agents. This typically involves either corticosteroids or ergotamine derivatives. The mainstay of prophylactic therapy is verapamil. Lithium, divalproex sodium, or topiramate may also be useful. As the sophistication of functional neuroimaging increases, so too will our ability to better understand the anatomic and metabolic perturbations that underlie cluster headache.

Resident and Fellow Section

“…Most clinicians consider verapamil the preventative therapy of choice for both episodic and chronic cluster headache, 11 hence why it was chosen for prophylaxis. Corticosteroids (prednisone and dexamethasone) are the most rapidly acting prophylactic agents for cluster headache 12 but avoided for this patient given her known adrenal failure. The combination of autonomic symptoms with neuralgiform pain closely related to SUNCT was the rationale for utilizing carbamazepine as this has been shown to have some partial effect in patients with SUNCT.…”

Calcium channel blocker use is associated with lower fasting serum glucose among adults with diabetes from the REGARDS study

“…Verapamil, an L-type CCB, has been used widely in clinical practice to treat hypertension [10], cardiac arrhythmias [11], cluster headaches [12], and migraines [13], but not to lower blood glucose for diabetes. Since the previous evidence of a hypoglycemic effect of verapamil comes from animal studies, there are few data in humans that can be compared with our findings.…”

White blood cell SPECT during active period of cluster headache and in remission

“…The good response to corticosteroids in CH, described in many articles [18,19], remains to be clarified in further studies. Earlier studies have shown that one of many effects of corticosteroids is to suppress spontaneous interleukin 2 (IL‐2) release [20,21].…”