Management of Trigeminal Autonomic Cephalalgias Including Chronic Cluster

Abstract

ImportanceTrigeminal autonomic cephalalgias (TACs) comprise a unique collection of primary headache disorders characterized by moderate or severe unilateral pain, localized in in the area of distribution of the first branch of the trigeminal nerve, accompanied by cranial autonomic symptoms and signs. Most TACs are rare diseases, which hampers the possibility of performing randomized clinical trials and large studies. Therefore, knowledge of treatment efficacy must be based only on observational studies, rare disease registries, and case reports, where real-world data and evidence play an important role in health care decisions.ObservationsChronic cluster headache is the most common of these disorders, and the literature offers some evidence from randomized clinical trials to support the use of pharmacologic and neurostimulation treatments. Galcanezumab, a monoclonal antibody targeting the calcitonin gene-related peptide, was not effective at 3 months in a randomized clinical trial but showed efficacy at 12 months in a large case series. For the other TACs (ie, paroxysmal hemicrania, hemicrania continua, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms), only case reports and case series are available to guide physicians in everyday management.Conclusions and RelevanceThe accumulation of epidemiologic, pathophysiologic, natural history knowledge, and data from case series and small controlled trials, especially over the past 20 years from investigators around the world, has added to the previously limited evidence and has helped advance and inform the treatment approach to rare TACs, which can be extremely challenging for clinicians.

Effects of Intravenous Eptinezumab vs Placebo on Headache Pain and Most Bothersome Symptom When Initiated During a Migraine Attack

“…This requirement ensured the enrollment of patients who could be considered candidates for preventive treatment in line with current guidance, 14,15,19 but was less stringent than controlled daily diaries to establish migraine frequency. Second, this inclusion criterion (4-15 migraine days per month) also diverged from current guidance for studies of acute migraine treatment-which exclude patients with chronic migraine (limiting the population to 2-8 migraine days per month) 20,21 -resulting in a population with more frequent and severe migraine than those who are included in acute migraine trials and underscoring that the methodology of this study was intended instead to show that eptinezumab could be used to treat and prevent migraine in the population of patients eligible for preventive treatment. Third, the generalizability of these study results may be limited due to the high proportions of female, White, and non-Hispanic or non-Latino patients enrolled.…”

Cluster Headache, SUNCT, and SUNA

“…Episodic cluster headache is 6 to 25 times more common than chronic cluster headache; interestingly, chronic cluster headache is more prevalent in women compared with men and in Europe and North America compared with Asia. 10,[17][18][19][20][21] Up to 15% of patients can transition from one subtype to another, 22 and there have been cases where patients transition multiple times.…”

“…Cluster headache has two subtypes: episodic, which has headache-free remission periods of 3 months or longer per year, and chronic, which has shorter or absent remission periods. Episodic cluster headache is 6 to 25 times more common than chronic cluster headache; interestingly, chronic cluster headache is more prevalent in women compared with men and in Europe and North America compared with Asia 10,17-21 . Up to 15% of patients can transition from one subtype to another, 22 and there have been cases where patients transition multiple times.…”

“…There are no diagnostic tests for SUNCT or SUNA, and thus the diagnostic criteria are based on clinical features ( table 6-4 25 ). The average attack duration is 61 seconds and the frequency is 28 attacks per day, with high variability between patients 20,73 . Patients are equally divided in presenting with one of three attack types—single stabs, groups of stabs, or a sawtooth pattern—and many patients have more than one attack type 8,74 .…”

Neues bei Kopfschmerzen 2022–2023

“…Neuere Literaturübersichten fassen die bisherigen Ergebnisse von Studien zur Akuttherapie von Clusterattacken zusammen. Dabei sind am besten wirksam [57,58]…”