Cluster Headaches

00:01 Let's start with the cluster and understand a little bit more about cluster.

00:05 Cluster causes severe often very severe unilateral orbital or supra-orbital head pain that may also spread into the temporal region with episodes lasting 15-180 minutes without treatment.

00:20 The headache is accompanied by ipsilateral conjunctival injection, nasal congestion, rhinorrhea, eyelid edema, facial sweating, miosis or change in pupillary ptosis or a sense of agitation.

00:32 You can see the prominent autonomic features that characterize this condition.

00:37 Attack frequency is often every other day to 8 attacks in a day and they cluster around the evening or nocturnally.

00:46 They cannot be attributed to another disorder and patients must have at least 5 attacks, meeting the above criteria.

00:52 So they need these clusters where they have attacks every other day to 8 per day for a period of weeks, and must have 5 attacks meeting those criteria.

01:02 The differential diagnosis for cluster is quite long.

01:06 We can see other headache syndromes other TACS- episodic paroxysmal hemicrania which we'll talk about.

01:12 Trigeminal neuralgia, hypnic headache, idiopathic stabbing headache, as well as secondary causes of headache.

01:18 Tolosa-hunt syndrome, acute-angle glaucoma, trigeminal neuralgia, tumors of the pituitary/parasellar region, meningioma.

01:27 Vascular abnormalities like arteriovenous malformations or dissection.

01:31 And so patients who are concerned about a secondary cause do undergo imaging prior to management or often contemporaneous to at the same time as management to rule out some of these secondary causes when evaluating a patient with cluster.

01:46 In addition, we can see infectious causes maxillary sinusitis, and trauma.

01:53 What are some of the clinical features of cluster? Alcohol, nitroglycerin and histamine can trigger attacks during the cluster period.

02:01 But not in between the cluster attacks.

02:05 Patients will have episodes where they cluster and then that will be interspersed with a headache free interval that can last months or even years.

02:14 And in between those episodes of attacks, we don't see these triggers.

02:19 Increased blood histamine can be seen, there's an associated with a gastric acid secretion and peptic ulcer disease is more common.

02:26 There's also an associate with obstructive sleep apnea that may be related to some of the brainstem abnormalities and circuitry and melatonin dysfunction that we see in these patients.

02:35 We can see increased intraocular pressure, decreased nocturnal melatonin.

02:40 There's a nocturnal predominance of these and increased juggler CGRP as well as vasoactive intestinal peptide.

02:48 Treatment of cluster is very important and oral medications are ineffective.

02:53 They don't act quickly enough.

02:54 Again, the headaches last 15-180 minutes.

02:58 So by the time the patient has gone to get the pill, the headache may be gone but the headache is severe and does require treatment.

03:05 Typically, we think about subcutaneous or nasal triptans like sumatriptan.

03:10 This is fast acting and fast onset and so it can be used for patients right when they have the onset of that cluster.

03:17 Oxygen by nasal canula or facemask can be very effective.

03:21 Other agents can include the oral triptans.

03:24 They are very fast acting nasal DHE, lidocaine, olanzapine can be used.

03:30 A number of other agents have been tried and analgesics are usually ineffective for these patients and should not be used.

03:38 In patients who have refractory symptoms that do not respond to treatment, sometimes we consider more interventional approaches, occipital nerve blocks or other nerve blocks.

03:48 Superficial temporal artery injection or ligation can be considered in rare cases.

03:54 Ganglion neurolysis can be considered, deep brain stimulation and Botox.

03:58 Again, for patients who are particularly refractory, we would consider escalation to some of these more interventional approaches.

04:05 What about prophylaxis? This is very important for these patients who will have clusters of headaches that are quite severe.

04:11 There's a number of medicines that have good data to support their use.

04:14 Verapamil is one that we think about.

04:16 It's effective in episodic and chronic forms of cluster with few adverse effects though you can see those here.

04:23 Lithium is used and this is one of the more effective agents to treat chronic cluster.

04:28 It does have a narrow therapeutic margin therapeutic index.

04:32 And so we do follow levels in those patients to make sure they're not super therapeutic.

04:36 And then a number of other agents that you see here both in and outside the United States can be used.

04:41 The ergotamine derivatives have been used.

04:42 Sometimes we consider prednisone, topiramate as a second or more ladder agent that we would consider in addition to gabapentin and valproic acid.