Cluster headache medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Saumya Easaw, M.B.B.S.[2]

Medical Therapy

Cluster headaches often go undiagnosed for many years, being confused with migraine or other causes of headache.[1]

Medically, cluster headaches are considered benign, but because of the extreme and often debilitating pain associated with them, a severe attack is nevertheless treated as a medical emergency by doctors who are familiar with the condition. Because of the relative rareness of the condition and ambiguity of the symptoms, some sufferers may not receive treatment in the emergency room and patients may even be mistaken as exhibiting drug-seeking behavior.

Over-the-counter pain medications (such as aspirin, paracetamol, and ibuprofen) typically have no effect on the pain from a cluster headache. Unlike other headaches such as migraines and tension headaches, cluster headaches do not respond to biofeedback.

Some have reported partial relief from narcotic pain killers. Percocet (Oxycodone with paracetamol) has had widespread success amongst some cluster headache patients, especially males. Anecdotal evidence indicates that cluster headaches can be so excruciating that even morphine does little to ease the pain. However, some newer medications like fentanyl (and Percocet) have shown promise in early studies and use.

Medications to treat cluster headaches are classified as either abortives or prophylactics (preventatives). In addition, short-term transitional medications (such as steroids) may be used while prophylactic treatment is instituted and adjusted. With abortive treatments often only decreasing the duration of the headache and preventing it from reaching its peak rather than eliminating it entirely, preventive treatment is always indicated for cluster headaches, to be started at the first sign of a new cluster cycle.

In many cases, some doctors have tried the use of beta blockers as a treatment.

Abortive Treatment

During the onset of a cluster headache, the most rapid abortive treatment is the inhalation of pure oxygen (12-15 liters per minute in a non-rebreathing apparatus).[2] When used at the onset this can abort the attack in as little as 5 minutes. Once an attack is at its peak, oxygen therapy appears to have little effect. Alternative first-line treatment is subcutaneous administration of triptan drugs, like sumatriptan and zolmitriptan.[2] Because of the rapid onset of an attack, the triptan drugs are usually taken by subcutaneous injection rather than by mouth. While available as a nasal spray, these are seldom effective to sufferers of cluster headaches due to the swelling of the nasal passages during an attack.

Lidocaine and other topical anesthetics sprayed into the nasal cavity may relieve or stop the pain,[3] normally in a few minutes, but long term use is not suggested due to the side effects and possible damage to the nasal cavities.

Previously, vaso-constrictors such as ergot compounds were also used, and sufferers report a similar relief by taking strong cups of coffee immediately at the onset of an attack.

Sometimes, lying in a dark room will help a person if the pain is a side effect of Horner's Syndrome.

Cool showers have helped about 15% of people who try them; while not aborting the attack, they allow the body to cool and thus help to reduce the level of pain. Other abortive remedies that work for some include ice, hot showers, breathing cold air, caffeine, and drinking large amounts of water in the early stages of an attack. Vigorous exercise has been shown in some cases to be very effective in relieving and aborting an acute attack by increasing the levels of oxygen within the body. This could also be due to an increase in adrenaline and changes in blood pressure. Some people report that sexual intercourse and specifically orgasm may terminate an attack possibly by acutely modulating hypothalamic function.[4][5][6]

Prophylactic Treatment

A wide variety of prophylactic medicines are in use, and patient response to these is highly variable. Current European guidelines suggest the use of the calcium channel blocker verapamil at a dose of at least 240 mg daily. Steroids, such as prednisolone, are also effective, with a high dose given for the first five days before tapering down. Methysergide, lithium and the anticonvulsant topiramate are recommended as alternative treatments.[2]

Muscle relaxants and atypical anti-psychotics have also been used.

Magnesium supplements have been shown to be of some benefit in about 40% of patients. Melatonin has also been reported to help some.

Non-established and Research Approaches

There is substantial anecdotal evidence that serotonergic psychedelics such as psilocybin (mushrooms) and LSD and LSA d-Lysergic acid amide(Rivea corymbosa seeds) abort cluster periods and extend remission periods.[7][8] Melatonin, psilocybin, serotonin, and the triptan abortive drugs are closely-related tryptamines.

Dr. Andrew Sewell and Dr. John Halpern at McLean Hospital in Boston have investigated the ability of low doses of psilocybin ("magic mushrooms") to treat cluster headaches. Dr. Sewell examined medical records of 53 patients who had taken hallucinogenic mushrooms and reported in Neurology that the majority of them found partial or complete relief from cluster attacks.[9] A clinical study of these treatments under the auspices of MAPS is being developed by researchers at Harvard Medical School, McLean Hospital.[10]

Within the United States, the Controlled Substances Act (CSA) of 1970 makes it illegal to possess hallucinogens (including psilocybin and LSD), classifying them as Schedule I drugs with no legitimate medical use. Patients who use psilocybin to treat their symptoms face legal prosecution, although there are no known convictions.

References

  1. "Vast Majority of Cluster Headache Patients Are Initially Misdiagnosed, Dutch Researchers Report". World Headache Alliance. 21/8/2003. Retrieved 2006-10-08. Check date values in: |date= (help)
  2. 2.0 2.1 2.2 May A, Leone M, Afra J, Linde M, Sándor P, Evers S, Goadsby P (2006). "EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias". Eur J Neurol. 13 (10): 1066–77. doi:10.1111/j.1468-1331.2006.01566.x. PMID 16987158. Unknown parameter |month= ignored (help) Free Full Text (PDF)
  3. Mills T, Scoggin J (1997). "Intranasal lidocaine for migraine and cluster headaches". Ann Pharmacother. 31 (7–8): 914–5. PMID 9220056. Unknown parameter |month= ignored (help)
  4. Ekbom K, Lindahl J (1970). "Effect of induced rise of blood pressure on pain in cluster headache". Acta Neurol Scand. 46 (4): 585–600. PMID 4994083.
  5. Atkinson R (1977). "Physical fitness and headache". Headache. 17 (5): 189–91. PMID 924787. Unknown parameter |month= ignored (help)
  6. Gotkine M, Steiner I, Biran I. (2006). "Now dear, I have a headache! Immediate improvement of cluster headaches after sexual activity". J Neurol Neurosurg Psychiatry. 77 (11): 1296. PMID 17043304. Unknown parameter |month= ignored (help)- Abstract
  7. "Hallucinogenic Differential Diagnosis of Cluster headache {{subst:Ddxtable_noh}} Treatment of Neuro-Vascular Headaches". ClusterBusters. Retrieved 2006-09-22. line feed character in |title= at position 58 (help)
  8. Mark Honigsbaum (August 2, 2005). "Headache sufferers flout new drug law - Calls for clinical trials and rethink of legislation as patients claim that magic mushrooms can relieve excruciating condition". The Guardian. Retrieved 2006-09-22. [reprint by Multidisciplinary Association for Psychedelic Studies]
  9. Sewell R, Halpern J, Pope H (2006). "Response of cluster headache to psilocybin and LSD". Neurology. 66 (12): 1920–2. PMID 16801660. Unknown parameter |month= ignored (help) - a Brief Communications, also presented as:
    Sewell, R. Andrew, M.D.; Halpern, John M., M.D. "The Effects Of Psilocybin And LSD On Cluster Headache: A Series Of 53 Cases." Abstract. Presented to the National Headache Foundation’s Annual Headache Research Summit. February, 2006.
  10. "Research into psilocybin and LSD as potential treatments for people with cluster headaches". LSD and Psilocybin Research. Multidisciplinary Association for Psychedelic Studies. Retrieved 2006-09-22.



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