Diagnosis and treatment of cluster headache

Multidisciplinary Treatment for Headache in the Canadian Healthcare Setting

Background/Objectives:

Multidisciplinary treatment programs are seen as an effective way to treat patients with chronic illness. The purpose of this study was to describe a multidisciplinary headache program which was developed in the Canadian public healthcare setting, and to report on patient perceptions of the program and patient treatment outcomes.

Methods:

The Calgary Headache Assessment and Management Program (CHAMP) was developed with initial funding from Alberta Health, and continued with function from the Calgary Health Region. Patient perceptions of the program were obtained with questionnaires. Outcome measures for a cohort of patients who completed the Self-Management Workshop were obtained using standard headache related disability measures.

Results:

Patient perceptions of the education session, the Lifestyle Assessment, and the Self-Management Workshop were very positive. Headache Disability Inventory scores fell from 56.2 to 46.3 from baseline to three months post Self-Management Workshop (p<.001). Corresponding scores for the HIT-6 were 63.6 and 58.2 (p <.001).

Conclusions:

Multidisciplinary headache treatment programs can be developed in the Canadian public healthcare system. The program described here was well accepted by many patients and perceived to be useful by them. Headache related disability as measured by standard measures was significantly reduced after participation in the program.

Orofacial pain syndromes: evaluation and management

Patients will often visit their primary medical practitioner with orofacial pain complaints. Hence, it is important to recognize and have an understanding of these conditions to properly evaluate and potentially manage these disorders. If the practitioner is uncertain or uncomfortable with these conditions, then patient referral to a knowledgeable health care practitioner should be considered for further evaluation and management. In this article, the evaluation and management of various neuropathic, neurovascular, and vascular pains are discussed.

Trigeminal autonomic cephalalgias: a review and implications for dentistry

BACKGROUND

The authors review the epidemiology, clinical features, pathophysiology, diagnosis, treatment, orofacial presentations and dental implications of trigeminal autonomic cephalalgias (TACs): cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT).

TYPES OF STUDIES REVIEWED

The authors conducted PUBMED searches for the period from 1968 through 2007 using the terms "trigeminal autonomic cephalalgias," "cluster headache," "paroxysmal hemicrania," "short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing," "epidemiology," "pathophysiology," "treatment," "oral," "facial" and "dentistry." They gave preference to articles reporting randomized, controlled trials and those published in English-language peer-reviewed journals.

RESULTS

TACs refers to a group of headaches characterized by unilateral head pain, facial pain or both with accompanying autonomic features. Although their pathophysiologies are unclear, CH, PH and SUNCT may be differentiated according to their clinical characteristics. Current treatments for each of the TACs are useful in alleviating the pain, with few refractory cases requiring surgical intervention. Patients with TACs often visit dental offices seeking relief for their pain.

CLINICAL IMPLICATIONS

Although the prevalence of TACs is small, it is important for dentists to recognize the disorder and refer patients to a neurologist. This will avoid the pitfall of administering unnecessary and inappropriate traditional dental treatments in an attempt to alleviate the neurovascular pain.

[Cluster headache and other trigeminal-autonomic headaches]

Cluster headache is a primary headache with a male predominance that presents in two forms: episodic and chronic, occurring at 45-to 60-day intervals with one to three headaches a day lasting 45 min to 2 h. An attack starts by a violent unilateral retro-ocular pain with sympathetic signs such as tearing and rhinorrhea. Diagnosis is made by questioning and therefore requires no complementary tests. Treatment for the attack consists of injectable sumatriptan or oxygen therapy, with long-term treatment with verapamil, lithium salts, or Topiramate; in certain cases in which the number of attacks is greater than two, injections of corticosteroids at the emergence of the Arnold nerve can be used, or in cases of attacks resistant to all treatments, hypothalamus stimulation surgery can be useful.

Trigeminal autonomic cephalalgias. Part 1: cluster headache

Cluster headache is characterized by severe, strictly unilateral pain attacks lasting 15 to 180 minutes localized to orbital, temporal, and midface areas accompanied by ipsilateral autonomic features. It represents 1 of 3 primary headaches classified as trigeminal autonomic cephalalgias. While its prevalence is small, it is not uncommon for cluster headache patients to present at dental offices seeking relief for their pain. It is important for oral health care providers to recognize cluster headache and render an accurate diagnosis. This will avoid the pitfall of implementing unnecessary and inappropriate traditional dental treatments in hopes of alleviating this neurovascular pain. The following article is part 1 of a review on trigeminal autonomic cephalalgias and focuses on cluster headache. Aspects of cluster headache including its prevalence and incidence, genetics, pathophysiology, clinical presentation, classification and variants, diagnosis, medical management, and dental considerations are discussed.

Diagnosis and management of cervicogenic headache

Upper cervical pain and/or headaches originating from the C0 to C3 segments are pain-states that are commonly encountered in the clinic. The upper cervical spine anatomically and biomechanically differs from the lower cervical spine. Patients with upper cervical disorders fall into two clinical groups: (1) local cervical syndrome; and (2) cervicocephalic syndrome. Symptoms associated with various forms of both disorders often overlap, making diagnosis a great challenge. The recognition and categorization of specific provocation and limitation patterns lend to effective and accurate diagnosis of local cervical and cervicocephalic conditions.

[Treatment and prophylaxis for cluster headaches and other trigeminal autonomic headaches. Revised recommendations of the German Migraine and Headache Society]

Following the new IHS classification, cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT syndrome) are included in the classification as trigeminal autonomic cephalgias (TAC). The similarities of these syndromes suggest a considerable shared pathophysiology. These syndromes have in common that they involve activation of trigeminovascular nociceptive pathways with reflex cranial autonomic activation. Clinically, this physiology predicts pain with some combination of lacrimation, conjunctival injection, nasal congestion, or eyelid edema. Broadly the management of TAC comprises acute and prophylactic treatment. Some types of trigeminal autonomic headaches such as paroxysmal hemicrania and hemicrania continua have, unlike cluster headaches, a very robust response to indomethacin, leading to a consideration of indomethacin-sensitive headaches. This review covers the clinical picture and therapeutic options. Although studies following the criteria of evidence-based medicine (EBM) are rare, most patients can be treated sufficiently.

Cluster headache: pathogenesis, diagnosis, and management

Cluster headache is a stereotyped primary pain syndrome characterised by strictly unilateral severe pain, localised in or around the eye and accompanied by ipsilateral autonomic features. The syndrome is characterised by the circadian rhythmicity of the short-lived attacks, and the regular recurrence of headache bouts, which are interspersed by periods of complete remission in most individuals. Headaches often start about 1-2 h after falling asleep or in the early morning, and show seasonal variation, suggesting that the hypothalamus has a role in the illness. Consequently, the vascular theory has been superseded by recognition that neurovascular factors are more important. The increased familial risk suggests that cluster headache has a genetic component in some families. Neuroimaging has broadened our pathophysiological view and has led to successful treatment by deep brain stimulation of the hypothalamus. Although most patients can be treated effectively, some do not respond to therapy. Fortunately, time to diagnosis of cluster headache has improved. This is probably the result of a better understanding of the pathophysiology in combination with efficient treatment strategies, leading to a broader acceptance of the syndrome by doctors.