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May A, Evers S, Goadsby PJ, Leone M, Manzoni GC, Pascual J, Carvalho V, Romoli M, Aleksovska K, Pozo-Rosich P, Jensen RH. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol 2023; 30:2955-2979. [PMID: 37515405 DOI: 10.1111/ene.15956] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND PURPOSE Cluster headache is a relatively rare, disabling primary headache disorder with a major impact on patients' quality of life. This work presents evidence-based recommendations for the treatment of cluster headache derived from a systematic review of the literature and consensus among a panel of experts. METHODS The databases PubMed (Medline), Science Citation Index, and Cochrane Library were screened for studies on the efficacy of interventions (last access July 2022). The findings in these studies were evaluated according to the recommendations of the European Academy of Neurology, and the level of evidence was established using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). RECOMMENDATIONS For the acute treatment of cluster headache attacks, there is a strong recommendation for oxygen (100%) with a flow of at least 12 L/min over 15 min and 6 mg subcutaneous sumatriptan. Prophylaxis of cluster headache attacks with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is recommended. Corticosteroids are efficacious in cluster headache. To reach an effect, the use of at least 100 mg prednisone (or equivalent corticosteroid) given orally or at up to 500 mg iv per day over 5 days is recommended. Lithium, topiramate, and galcanezumab (only for episodic cluster headache) are recommended as alternative treatments. Noninvasive vagus nerve stimulation is efficacious in episodic but not chronic cluster headache. Greater occipital nerve block is recommended, but electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - Stefan Evers
- Department of Neurology, Lindenbrunn Hospital, Coppenbrügge, Germany
- Faculty of Medicine, University of Münster, Münster, Germany
| | - Peter J Goadsby
- NIHR King's CRF, SLaM Biomedical Research Centre, King's College London, London, UK
| | - Massimo Leone
- Neuroalgology Department, Foundation of the Carlo Besta Neurological Institute, IRCCS, Milan, Italy
| | | | - Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, Universidad de Cantabria and IDIVAL, Santander, Spain
| | - Vanessa Carvalho
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Bufalini Hospital, Cesena, Italy
| | | | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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Schindler EAD, Hendricks PS. Adapting psychedelic medicine for headache and chronic pain disorders. Expert Rev Neurother 2023; 23:867-882. [PMID: 37652000 DOI: 10.1080/14737175.2023.2246655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION While the majority of current research and development surrounds depression, demoralization, and substance use disorders, there are numerous reports of psychedelics having beneficial effects in other branches of medicine, including for headache disorders and chronic pain. AREAS COVERED This perspective reviews conventional forms of treatment for headache and other chronic pain disorders and describes historical, recent, and ongoing investigations of the therapeutic effects of psychedelics in these disorders. The first two clinical trials of psilocybin in headache disorders and recent case reports of psilocybin mushroom self-administration in chronic pain patients are described. This perspective highlights several factors related to the application of psychedelics in chronic pain disorders, comparing this with the standard psychedelic-assisted psychotherapy model of treatment. EXPERT OPINION When faced with a more constricted view of psychedelic medicine that features larger doses, underscores subjective effects in the mediation of therapeutic outcomes, and requires adjunctive psychotherapy to ensure safety and efficacy, the application of psychedelics in headache and chronic pain disorders may face challenges. It will be important to allow for flexibility and adaptation in protocols to evaluate different treatment paradigms, mechanisms of action, and the range of pharmacologic and extra-pharmacologic factors that affect psychedelic treatment outcomes.
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Affiliation(s)
- Emmanuelle A D Schindler
- Yale School of Medicine, Department of Neurology, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, Headache Center of Excellence, West Haven, CT, USA
| | - Peter S Hendricks
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Schindler EAD, Sewell RA, Gottschalk CH, Luddy C, Flynn LT, Zhu Y, Lindsey H, Pittman BP, Cozzi NV, D'Souza DC. Exploratory investigation of a patient-informed low-dose psilocybin pulse regimen in the suppression of cluster headache: Results from a randomized, double-blind, placebo-controlled trial. Headache 2022; 62:1383-1394. [PMID: 36416492 DOI: 10.1111/head.14420] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/25/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Using a patient-informed regimen, we conducted an exploratory randomized, double-blind, placebo-controlled study to systematically investigate the effects of psilocybin in cluster headache. BACKGROUND Sustained reductions in cluster headache burden after limited quantities of psilocybin-containing mushrooms are anecdotally reported, although to date there are no controlled studies investigating these effects. METHODS Participants were randomized to receive psilocybin (0.143 mg/kg) or placebo (microcrystalline cellulose) in a pulse of three doses, each ~5 days apart. Participants maintained headache diaries starting 2 weeks before and continuing through 8 weeks after the first drug session. A total of 16 participants were randomized to receive experimental drug and 14 were included in the final analysis. RESULTS In the 3 weeks after the start of the pulse regimen, the change in cluster attack frequency was 0.03 (95% confidence interval [CI] -2.6 to 2.6) attacks/week with placebo (baseline 8.9 [95% CI 3.8 to 14.0]) and -3.2 (95% CI -8.3 to 1.9) attacks/week with psilocybin (baseline 9.6 [95% CI 5.6 to 13.6]; p = 0.251). Group difference in change from baseline had a moderate effect size (d = 0.69). The effect size was small in episodic participants (d = 0.35) but large in chronic participants (d = 1.25), which remained over the entire 8-week period measured (d = 0.81). Changes in cluster attack frequency were not correlated with the intensity of acute psychotropic effects during psilocybin administration. Psilocybin was well-tolerated without any unexpected or serious adverse events. CONCLUSIONS Findings from this initial, exploratory study provide valuable information for the development of larger, more definitive studies. Efficacy outcomes were negative, owing in part to the small number of participants. The separation of acute psychotropic effects and lasting therapeutic effects underscores the need for further investigation into the mechanism(s) of action of psilocybin in headache disorders.
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Affiliation(s)
- Emmanuelle A D Schindler
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA.,Neurology Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.,Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - R Andrew Sewell
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | | | - Christina Luddy
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - L Taylor Flynn
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Yutong Zhu
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Hayley Lindsey
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA.,Neurology Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.,Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Brian P Pittman
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nicholas V Cozzi
- Neuropharmacology Laboratory, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Alexander Shulgin Research Institute, Lafayette, California, USA
| | - Deepak C D'Souza
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Psychiatry Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
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Prasad S, Mehadi A, Kaka N, Jhaveri S, Avanthika C, Patel N, Augustine I, Issani A. Diagnostic protocols and newer treatment modalities for cluster headache. Dis Mon 2022; 68:101316. [PMID: 35000758 DOI: 10.1016/j.disamonth.2021.101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cluster Headaches are one of the most arguably severe forms of primary headache syndrome that affects humans. Although it is relatively uncommon, it has a significant impact on the quality of life. It is a multifactorial disease that has risk factors ranging from seasonal changes, lifestyle habits to genetics. It occurs in 2 forms- Episodic and Chronic, each having its well-defined Diagnostic Criteria. Moreover, Cluster Headache has an exhaustive list of options for both Preventive and Abortive treatment. This article focuses on Cluster Headache, its pathophysiology, risk factors, differentials, and its diverse treatment modalities. In this study, an all-language literature search was conducted on Medline, Cochrane, Embase, and Google Scholar till October 2021. The following search strings and Medical Subject Headings (MeSH) terms were used: "Cluster Headache," "Triptans," "Neuromodulation," and "Migraine." We explored the literature on Cluster Headache for its epidemiology, pathophysiology, the role of various genes and how they bring about the disease as well as its episodic and chronic variants, and treatment options. Although we have a wide variety of options for Preventive and Abortive therapy, newer more effective pharmacological and non-pharmacological interventions are being developed, and must be integrated into new treatment protocols.
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Affiliation(s)
- Sakshi Prasad
- Faculty of Medicine, National Pirogov, Memorial Medical University, 21018, Vinnytsya, Ukraine.
| | | | - Nirja Kaka
- GMERS Medical College, Himmatnagar 383001, Gujarat, India.
| | - Sharan Jhaveri
- Smt. NHL Municipal Medical college, Ahmedabad 380006, India.
| | - Chaithanya Avanthika
- Karnataka Institute of Medical Sciences,PB Road, Hubli 580022, Karnataka, India.
| | - Neil Patel
- GMERS Medical College, Himmatnagar 383001, Gujarat, India.
| | - Ivan Augustine
- Government Medical college Thrissur 680596, Kerala,India.
| | - Ali Issani
- Baqai Medical University, Karachi, Pakistan.
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Schindler EAD. Psychedelics in the Treatment of Headache and Chronic Pain Disorders. Curr Top Behav Neurosci 2022; 56:261-285. [PMID: 35546382 DOI: 10.1007/7854_2022_365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The therapeutic potential of psychedelics in headache and chronic pain disorders is documented over decades of anecdotal and early investigational reports, which have paved the way for the first controlled studies of psilocybin and lysergic acid diethylamide (LSD) in these disorders. The reported lasting clinical effects after limited dosing with psychedelics present a novel means for disease management, but considerable further study will be required to address disease-specific treatments, uncover mechanism(s) of action, and verify safety. In this chapter, these topics are reviewed with particular attention to the neurobiological systems that offer potential sources of psychedelics' unique clinical effects in headache and pain.
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Affiliation(s)
- Emmanuelle A D Schindler
- Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Yale School of Medicine, New Haven, CT, USA.
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Tsai CL, Lin GY, Wu SK, Yang FC, Wang SJ. Chronic Cluster Headache Update and East-West Comparisons: Focusing on Clinical Features, Pathophysiology, and Management. Curr Pain Headache Rep 2020; 24:68. [PMID: 32990832 DOI: 10.1007/s11916-020-00902-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW This review provides an update on chronic cluster headache (CH) focusing on clinical features, pathophysiology, and management as well as comparisons between Eastern and Western populations. RECENT FINDINGS Chronic CH in Eastern populations was relatively rare, compared to that in Western populations. Lacrimation and/or conjunctival injection is the most frequently reported cranial autonomic symptom, and visual aura is predominant in chronic CH patients. Neuroimaging evidence in both ethnic groups suggests that CH pathophysiology involves the hypothalamus and pain-modulatory areas, with dynamic alternations between CH episodes. Recent evidence indicates that midbrain dopaminergic systems may participate in CH chronicity. Noteworthy advances have emerged in neuromodulatory therapies for chronic CH, but treatment with calcitonin gene-related peptide (CGRP) monoclonal antibodies has been unsuccessful. Recent evidence shows divergence of chronic CH between Eastern and Western populations. Neuromodulatory therapies but not CGRP inhibition is effective in this intractable patient group.
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Affiliation(s)
- Jasper Mecklenburg
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Uwe Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Abstract
Cluster headache is characterised by attacks of excruciating unilateral headache or facial pain lasting 15 min to 3 h and is seen as one of the most intense forms of pain. Cluster headache attacks are accompanied by ipsilateral autonomic symptoms such as ptosis, miosis, redness or flushing of the face, nasal congestion, rhinorrhoea, peri-orbital swelling and/or restlessness or agitation. Cluster headache treatment entails fast-acting abortive treatment, transitional treatment and preventive treatment. The primary goal of prophylactic and transitional treatment is to achieve attack freedom, although this is not always possible. Subcutaneous sumatriptan and high-flow oxygen are the most proven abortive treatments for cluster headache attacks, but other treatment options such as intranasal triptans may be effective. Verapamil and lithium are the preventive drugs of first choice and the most widely used in first-line preventive treatment. Given its possible cardiac side effects, electrocardiogram (ECG) is recommended before treating with verapamil. Liver and kidney functioning should be evaluated before and during treatment with lithium. If verapamil and lithium are ineffective, contraindicated or discontinued because of side effects, the second choice is topiramate. If all these drugs fail, other options with lower levels of evidence are available (e.g. melatonin, clomiphene, dihydroergotamine, pizotifen). However, since the evidence level is low, we also recommend considering one of several neuromodulatory options in patients with refractory chronic cluster headache. A new addition to the preventive treatment options in episodic cluster headache is galcanezumab, although the long-term effects remain unknown. Since effective preventive treatment can take several weeks to titrate, transitional treatment can be of great importance in the treatment of cluster headache. At present, greater occipital nerve injection is the most proven transitional treatment. Other options are high-dose prednisone or frovatriptan.
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Abstract
OBJECTIVE To provide a narrative review of clinical development programs for non-oral, non-injectable formulations of dihydroergotamine (DHE) for the treatment of migraine. BACKGROUND Dihydroergotamine was one of the first "synthetic drugs" developed in the 20th century for treating migraine. It is effective and recommended for acute migraine treatment. Since oral DHE is extensively metabolized, it must be given by a non-oral route. Intravenous DHE requires healthcare personnel to administer, subcutaneous/intramuscular injection is challenging to self-administer, and the approved nasal spray formulation exhibits low bioavailability and high variability that limits its efficacy. Currently there are several attempts underway to develop non-oral, non-injected formulations of DHE. METHOD A systematic search of MEDLINE/PubMed and ClinicalTrials.gov databases, then narrative review of identified reports, focusing on those published in the last 10 years. RESULTS Of 1881 references to DHE from a MEDLINE/PubMed search, 164 were from the last 10 years and were the focus of this review. Further cross reference was made to ClinicalTrials.gov for 19 clinical studies, of which some results have not yet been published, or are studies that are currently underway. Three nasal DHE products are in clinical development, reawakening interest in this route of delivery for migraine. Other routes of DHE administration have been, or are being, explored. CONCLUSION There is renewed appreciation for DHE and the need for non-oral, non-injected delivery is now being addressed.
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Petersen AS, Barloese MCJ, Snoer A, Soerensen AMS, Jensen RH. Verapamil and Cluster Headache: Still a Mystery. A Narrative Review of Efficacy, Mechanisms and Perspectives. Headache 2019; 59:1198-1211. [DOI: 10.1111/head.13603] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2019] [Indexed: 01/04/2023]
Affiliation(s)
- Anja S. Petersen
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
| | - Mads C. J. Barloese
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging Hvidovre Hospital Hvidovre Denmark
| | - Agneta Snoer
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
| | - Anne Mette S. Soerensen
- Department of Clinical Pharmacology Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Rigmor H. Jensen
- Department of Neurology, Danish Headache Center Rigshospitalet‐Glostrup Glostrup Denmark
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Karri J, Abd-Elsayed A. Dihydroergotamine Infusion Therapy. Infusion Therapy 2019:95-105. [DOI: 10.1007/978-3-030-17478-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Wei J, Robbins MS. Greater Occipital Nerve Injection versus Oral Steroids for Short Term Prophylaxis of Cluster Headache: A Retrospective Comparative Study. Headache 2018; 58:852-858. [DOI: 10.1111/head.13334] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Jerry Wei
- Department of Neurology; Montefiore Headache Center; Bronx NY USA
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Abstract
Cluster headache is characterized by severe, unilateral headache attacks of orbital, supraorbital or temporal pain lasting 15-180 min accompanied by ipsilateral lacrimation, rhinorrhea and other cranial autonomic manifestations. Cluster headache attacks need fast-acting abortive agents because the pain peaks very quickly; sumatriptan injection is the gold standard acute treatment. First-line preventative drugs include verapamil and carbolithium. Other drugs demonstrated effective in open trials include topiramate, valproic acid, gabapentin and others. Steroids are very effective; local injection in the occipital area is also effective but its prolonged use needs caution. Monoclonal antibodies against calcitonin gene-related peptide are under investigation as prophylactic agents in both episodic and chronic cluster headache. A number of neurostimulation procedures including occipital nerve stimulation, vagus nerve stimulation, sphenopalatine ganglion stimulation and the more invasive hypothalamic stimulation are employed in chronic intractable cluster headache.
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Abstract
Cluster headache is an excruciating, strictly one-sided pain syndrome with attacks that last between 15 minutes and 180 minutes and that are accompanied by marked ipsilateral cranial autonomic symptoms, such as lacrimation and conjunctival injection. The pain is so severe that female patients describe each attack as worse than childbirth. The past decade has seen remarkable progress in the understanding of the pathophysiological background of cluster headache and has implicated the brain, particularly the hypothalamus, as the generator of both the pain and the autonomic symptoms. Anatomical connections between the hypothalamus and the trigeminovascular system, as well as the parasympathetic nervous system, have also been implicated in cluster headache pathophysiology. The diagnosis of cluster headache involves excluding other primary headaches and secondary headaches and is based primarily on the patient's symptoms. Remarkable progress has been achieved in developing effective treatment options for single cluster attacks and in developing preventive measures, which include pharmacological therapies and neuromodulation.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany
| | | | - Delphine Magis
- University Department of Neurology CHR, CHU de Liege, Belgium
| | - Patricia Pozo-Rosich
- Headache and Craniofacial Pain Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Headache Research Group, VHIR, Universitat Autònoma Barcelona, Barcelona, Spain
| | - Stefan Evers
- Department of Neurology, Krankenhaus Lindenbrunn, Coppenbrügge, Germany
| | - Shuu-Jiun Wang
- Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Lambru G, Shanahan P, Matharu M. Exacerbation of SUNCT and SUNA syndromes during intravenous dihydroergotamine treatment: A case series. Cephalalgia 2015; 35:1115-24. [PMID: 25667300 DOI: 10.1177/0333102415570495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 01/05/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND The management of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and with short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA) remains challenging in view of the limited understanding of their pathophysiological mechanisms. METHODS An initial observation that patients with both chronic migraine (CM) or cluster headache (CH) and SUNCT/SUNA receiving intravenous dihydroergotamine (IV DHE) had complained of dramatic worsening of the latter led to review of the case notes of patients with CM or CH and co-existent SUNCT/SUNA seen between 2008 and 2013 and who had a trial of IV DHE. RESULTS Twenty-four patients were identified. IV DHE was ineffective for SUNCT/SUNA in 16 patients, while one patient reported a marginal improvement. Five patients reported dramatic worsening of the SUNCT/SUNA. Moreover, two patients developed new-onset SUNA during their first IV DHE infusion. Out of these seven patients, those requiring repeated courses of IV DHE consistently experienced exacerbations of SUNCT/SUNA which were suppressed with IV lidocaine. CONCLUSIONS DHE is an ineffective treatment option for SUNCT and SUNA. Physicians who intend to offer IV DHE to CH or CM patients should warn them that IV DHE could exacerbate and possibly even lead to a de novo onset of SUNCT/SUNA. In view of the reported worsening or new onset of SUNCT/SUNA in patients using dopamine agonists for the treatment of pituitary prolactinomas, we speculate that DHE might worsen or induce SUNCT and SUNA, at least in a sub-group of patients, through a perturbation in the dopaminergic system.
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Affiliation(s)
| | - Paul Shanahan
- The National Hospital for Neurology and Neurosurgery, London, UK
| | - Manjit Matharu
- Institute of Neurology, UCL, London, UK The National Hospital for Neurology and Neurosurgery, London, UK
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Donnet A, Demarquay G, Ducros A, Geraud G, Giraud P, Guegan-Massardier E, Lucas C, Navez M, Valade D, Lanteri-Minet M. Recommandations pour le diagnostic et le traitement de l’algie vasculaire de la face. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.douler.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Costa A, Antonaci F, Ramusino MC, Nappi G. The Neuropharmacology of Cluster Headache and other Trigeminal Autonomic Cephalalgias. Curr Neuropharmacol 2015; 13:304-23. [PMID: 26411963 PMCID: PMC4812802 DOI: 10.2174/1570159x13666150309233556] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 12/19/2014] [Accepted: 03/06/2015] [Indexed: 11/22/2022] Open
Abstract
Trigeminal autonomic cephalalgias (TACs) are a group of primary headaches including cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Another form, hemicrania continua (HC), is also included this group due to its clinical and pathophysiological similarities. CH is the most common of these syndromes, the others being infrequent in the general population. The pathophysiology of the TACs has been partly elucidated by a number of recent neuroimaging studies, which implicate brain regions associated with nociception (pain matrix). In addition, the hypothalamic activation observed in the course of TAC attacks and the observed efficacy of hypothalamic neurostimulation in CH patients suggest that the hypothalamus is another key structure. Hypothalamic activation may indeed be involved in attack initiation, but it may also lead to a condition of central facilitation underlying the recurrence of pain episodes. The TACs share many pathophysiological features, but are characterised by differences in attack duration and frequency, and to some extent treatment response. Although alternative strategies for the TACs, especially CH, are now emerging (such as neurostimulation techniques), this review focuses on the available pharmacological treatments complying with the most recent guidelines. We discuss the clinical efficacy and tolerability of the currently used drugs. Due to the low frequency of most TACs, few randomised controlled trials have been conducted. The therapies of choice in CH continue to be the triptans and oxygen for acute treatment, and verapamil and lithium for prevention, but promising results have recently been obtained with novel modes of administration of the triptans and other agents, and several other treatments are currently under study. Indomethacin is extremely effective in PH and HC, while antiepileptic drugs (especially lamotrigine) appear to be increasingly useful in SUNCT. We highlight the need for appropriate studies investigating treatments for these rare, but lifelong and disabling conditions.
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Affiliation(s)
- Alfredo Costa
- National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, via Mondino 2, 27100 Pavia, Italy.
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Donnet A, Demarquay G, Ducros A, Geraud G, Giraud P, Guegan-Massardier E, Lucas C, Navez M, Valade D, Lanteri-Minet M. Recommandations pour le diagnostic et le traitement de l’algie vasculaire de la face. Rev Neurol (Paris) 2014; 170:653-70. [DOI: 10.1016/j.neurol.2014.03.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 03/26/2014] [Indexed: 12/24/2022]
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Affiliation(s)
- Juan A. Pareja
- Neurological Department; University Hospital Quirón Madrid; Madrid Spain
- Neurological Department; University Hospital Fundación Alcorcón; Alcorcón Spain
| | - Mónica Álvarez
- Neurological Department; University Hospital Quirón Madrid; Madrid Spain
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Vollbracht S, Grosberg BM. Treatment of Trigeminal Autonomic Cephalalgias Including Cluster Headache. Headache 2013. [DOI: 10.1002/9781118678961.ch17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Cluster headache pain is very intense, usually increases in intensity very rapidly from onset, and attacks are often frequent. These clinical features result in significant therapeutic challenges. The most effective pharmacological treatment options for acute cluster attack include subcutaneous sumatriptan, 100% oxygen, and intranasal zolmitriptan. Subcutaneous or intramuscular dihydroergotamine and intranasal sumatriptan are additional options. Transitional therapy is applicable mainly for patients with high-frequency (>2 attacks per day) episodic cluster headache, and options include short courses of high-dose oral corticosteroids, dihydroergotamine, and occipital nerve blocks with local anesthetic and steroids. Prophylactic therapy is important both for episodic and chronic cluster headache, and the main options are verapamil and lithium. Verapamil is drug of first choice but may cause cardiac arrhythmias, and periodic electrocardiograms (EKGs) during dose escalation are important. Many other drugs are also in current use, but there is an insufficient evidence base to recommend them.
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Affiliation(s)
- Werner J Becker
- Department of Clinical Neurosciences, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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Lambru G, Matharu MS. Trigeminal autonomic cephalalgias: A review of recent diagnostic, therapeutic and pathophysiological developments. Ann Indian Acad Neurol 2012; 15:S51-61. [PMID: 23024564 PMCID: PMC3444219 DOI: 10.4103/0972-2327.100007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 09/16/2011] [Accepted: 11/24/2011] [Indexed: 11/25/2022] Open
Abstract
The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders that are characterized by strictly unilateral trigeminal distribution pain occurring in association with ipsilateral cranial autonomic symptoms. This group includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. These disorders are very painful, often considered to be some of the most painful conditions known to mankind, and consequently are highly disabling. They are distinguished by the frequency of attacks of pain, the length of the attacks and very characteristic responses to medical therapy, such that the diagnosis can usually be made clinically, which is important because it dictates therapy. The management of TACs can be very rewarding for physicians and highly beneficial to patients.
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Affiliation(s)
- Giorgio Lambru
- Institute of Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Sarchielli P, Granella F, Prudenzano MP, Pini LA, Guidetti V, Bono G, Pinessi L, Alessandri M, Antonaci F, Fanciullacci M, Ferrari A, Guazzelli M, Nappi G, Sances G, Sandrini G, Savi L, Tassorelli C, Zanchin G. Italian guidelines for primary headaches: 2012 revised version. J Headache Pain 2012; 13 Suppl 2:S31-70. [PMID: 22581120 PMCID: PMC3350623 DOI: 10.1007/s10194-012-0437-6] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105–190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version.
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Affiliation(s)
- Paola Sarchielli
- Headache Centre, Neurologic Clinic, University of Perugia, Perugia, Italy.
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Abstract
The objective was to determine the respiratory toxicity of MAP0004, orally inhaled dihydroergotamine (DHE), via inhalation for six months. Forty beagle dogs (twenty females, twenty males) were treated by nose-only inhalation for 182 days. Groups 2 through 5 received MAP0004 (mean doses: 0.045, 0.154, 0.44, 0.825 mg/kg); Group 1 received vehicle only. Groups 1 through 4 received single thirty-minute exposures, whereas Group 5 was exposed twice daily for thirty minutes. Toxicity was assessed from clinical observations, objective evaluations, and clinical and anatomical pathology. Systemic effects were scabbing of ear tips in Groups 3, 4, and 5 and excessive salivation and emesis, observed in Group 5. No changes were observed in the lungs in any dose group. Minimal treatment-related microscopic changes were observed in the respiratory nasal epithelium only in Group 5. No plexiform, vascular media, or fibroproliferative changes in any heart valves were observed in any group. Expected systemic pharmacologic effects were observed only at MAP0004 target doses ≥ 0.224 mg/kg (achieved doses > 0.154 mg/kg), which was more than five times the maximum daily intravenous (IV) human clinical dose of DHE, and more than twenty times the systemic equivalent dose of MAP0004. The no-observed adverse effect level (NOAEL) was the achieved inhaled dose of 0.045 mg/kg, or four times the human clinical dose of MAP0004.
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Affiliation(s)
- Thomas A Armer
- MAP Pharmaceuticals, Inc., Mountain View, California 94043, USA.
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Abstract
IMPORTANCE OF THE FIELD Cluster headache belongs to the trigemino-autonomic cephalgias and is one of the most devastating idiopathic pain syndromes. Despite its extreme severity and its prevalence of about 0.1%, little attention has been paid to this painful syndrome by either basic or clinical research. AREAS COVERED IN THIS REVIEW All clinical trials on the acute and prophylactic drug treatment of cluster headache are reviewed, including review articles and book chapters. WHAT THE READER WILL GAIN The treatment of cluster headache is based on acute and prophylactic drug treatment. Oxygen inhalation, subcutaneous or intranasal sumatriptan, and intranasal zolmitriptan are recommended to stop an attach. For prophylaxis, verapamil is drug of first choice. Other drugs efficacious in cluster headache are steroids, lithium, some anticonvulsants and methysergide. Recently, interventional procedures have been studied for the treatment of refractory cluster headache. In the future, new anticonvulsants and unconventional ways of immunotherapy should be evaluated. TAKE HOME MESSAGE In most cases, cluster headache can be treated sufficiently (i.e., with sufficient quality of life) by an individual concept of acute and prophylactic drug treatment.
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Affiliation(s)
- Stefan Evers
- University of Münster, Department of Neurology, Albert-Schweitzer-Str. 33, 48129 Münster, Germany.
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Leone M, Franzini A, Proietti Cecchini A, Mea E, Broggi G, Bussone G. Management of Chronic Cluster Headache. Curr Treat Options Neurol 2011; 13:56-70. [DOI: 10.1007/s11940-010-0106-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Karst M, Halpern JH, Bernateck M, Passie T. The non-hallucinogen 2-bromo-lysergic acid diethylamide as preventative treatment for cluster headache: An open, non-randomized case series. Cephalalgia 2010; 30:1140-4. [DOI: 10.1177/0333102410363490] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Leone M, Franzini A, Cecchini AP, Mea E, Broggi G, Bussone G. Cluster headache: pharmacological treatment and neurostimulation. Nat Rev Neurol 2009; 5:153-62. [PMID: 19262591 DOI: 10.1038/ncpneuro1050] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 01/13/2009] [Indexed: 11/08/2022]
Abstract
Cluster headache is a primary headache syndrome that is characterized by excruciatingly severe, strictly unilateral attacks of orbital, supraorbital or temporal pain, which last 15-180 min and are accompanied by ipsilateral autonomic manifestations (e.g. lacrimation and rhinorrhea). The attacks typically occur with circadian rhythmicity, being experienced at fixed hours of the day or night. In episodic cluster headache, attacks usually occur daily in 6-12-week bouts (cluster periods) followed by remission periods. In chronic cluster headache there is no notable remission. Cluster headache attacks reach full intensity very quickly and abortive agents need to be administered without delay. The pathophysiology of cluster headache is imperfectly understood and treatment has so far been mainly empirical. However, neuroimaging studies have prompted the successful use of hypothalamic stimulation to treat the condition. More recently, the less invasive technique of occipital nerve stimulation has shown promise in drug-refractory chronic cluster headache. This Review discusses both acute and preventive treatments for cluster headache and includes suggestions of how to use the available medications. The rationale, study results and selection criteria for neurostimulation procedures are also summarized, as are the disadvantages of these procedures.
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Abstract
The study of migraine has yielded many benefits for headache patients. Little research, however, has been performed on refractory migraine (RM) headache, a term often used interchangeably with intractable migraine. This may be a consequence of a lack of a well-accepted definition. In a survey performed by the Refractory Headache Special Interest Section (RHSIS) on the American Headache Society (AHS) in 2006, 58% of the members agreed that a definition for refractory headache should be added to the International Classification of Headache Disorders-2. A PubMed search identified 21 articles that defined refractory or intractable headache/migraine. Sixteen (76%) defined the term "refractory" and 5 (24%) defined the term "intractable." Many of these definitions did not address the need for an adequate trial of a preventive medicine, disability, and medication overuse. An operational definition will allow us to better characterize the disorder, address unmet medical needs, and identify the most effective treatments. RHSIS of the AHS has proposed a definition of RM. It is our hope that this definition will spur interest in this entity and will lead to further research in the area.
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Shareef AH, Dafer RM, Jay WM. Neuro-ophthalmologic manifestations of primary headache disorders. Semin Ophthalmol 2008; 23:169-77. [PMID: 18432543 DOI: 10.1080/08820530802012937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Headaches are the most common disorders of the central nervous system affecting 46% of the adult population worldwide. Headaches may be lifelong illnesses, often associated with substantial disability for the individual and the population as a whole. The International Classification of Headache Disorders (ICHD-II) codifies headache disorders into fourteen categories, predominantly primary headaches and secondary headache disorders. Primary headache disorders, mainly migraine and trigeminal autonomic cephalgias (TACs), are frequently associated with neuro-ophthalmologic manifestations. Ophthalmologists are often the first physicians to be involved in the deciphering of headache-related visual disturbances. This article reviews two major primary headache disorders, migraine and trigeminal autonomic cephalgias, and discusses their neuro-ophthalmic complications, clinical presentation, and treatment.
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Abstract
Following the revised International Headache Society criteria, a group of short-lasting headaches associated with autonomic symptoms, the so called trigeminal autonomic cephalgias, were newly recognized. The trigeminal autonomic cephalgias include cluster headache, paroxysmal hemicranias and a syndrome involving short-lasting unilateral neuralform cephalgias with conjunctival injection and tearing (SUNCT) syndrome. In all of these syndromes, the half-sided head pain and cranial autonomic symptoms are prominent. All of the trigeminal autonomic cephalgias differ in duration, frequency and rhythmicity of the attacks, the intensity of pain and autonomic symptoms, as well as treatment options. This review gives a brief clinical description of the headache disorders and recent pathophysiological findings, as well as an overview of the treatment of cluster headache, paroxysmal hemicranias and SUNCT syndrome.
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Affiliation(s)
- Arne May
- University of Hamburg, Department of Systems Neuroscience, Martinistr. 52, Hamburg, Germany.
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May A, Leone M, Afra J, Linde M, Sándor PS, Evers S, Goadsby PJ. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol 2006; 13:1066-77. [PMID: 16987158 DOI: 10.1111/j.1468-1331.2006.01566.x] [Citation(s) in RCA: 269] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cluster headache and the other trigeminal-autonomic cephalalgias [paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome] are rare but very disabling conditions with a major impact on the patient's quality of life. The objective of this study was to give evidence-based recommendations for the treatment of these headache disorders based on a literature search and consensus amongst a panel of experts. All available medical reference systems were screened for any kind of studies on cluster headache, paroxysmal hemicrania and SUNCT syndrome. The findings in these studies were evaluated according to the recommendations of the European Federation of Neurological Societies resulting in level A, B or C recommendations and good practice points. For the acute treatment of cluster headache attacks, oxygen (100%) with a flow of at least 7 l/min over 15 min and 6 mg subcutaneous sumatriptan are drugs of first choice. Prophylaxis of cluster headache should be performed with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy or tolerability). Although no class I or II trials are available, steroids are clearly effective in cluster headache. Therefore, the use of at least 100 mg methylprednisone (or equivalent corticosteroid) given orally or at up to 500 mg i.v. per day over 5 days (then tapering down) is recommended. Methysergide, lithium and topiramate are recommended as alternative treatments. Surgical procedures, although in part promising, require further scientific evaluation. For paroxysmal hemicranias, indomethacin at a daily dose of up to 225 mg is the drug of choice. For treatment of SUNCT syndrome, large series suggest that lamotrigine is the most effective preventive agent, with topiramate and gabapentin also being useful. Intravenous lidocaine may also be helpful as an acute therapy when patients are extremely distressed and disabled by frequent attacks.
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Affiliation(s)
- A May
- Department of Systems Neuroscience, University of Hamburg, Hamburg, Germany.
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Abstract
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.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, Universitäts-Krankenhaus Eppendorf, Martinistr 52, D-20246 Hamburg, Germany.
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Charles JA. Outpatient Continuous Intravenous Dihydroergotamine for Refractory Headache. Headache 2005; 45:394-5. [PMID: 15836585 DOI: 10.1111/j.1526-4610.2005.05082_4.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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