Abstract & Commentary
By Michael Rubin, MD, Professor of Clinical Neurology, NewYork-Presbyterian Hospital, Cornell Campus. Dr. Rubin is on the speaker's bureau for Athena Diagnostics, and does research for Pfizer and Merck.
Synopsis: Cluster headache may be accompanied by a variety of neurological manifestations, and responds well to triptans and oxygen therapy.
Source: Schurks M, et al. Cluster Headaches: Clinical Presentation, Lifestyle Features, and Medical Treatment. Headache. 2006;46:1246-1254.
Using international headache society criteria to establish a diagnosis of cluster headache (CH), 246 such patients were recruited from the Headache Clinic at the University Hospital in Essen, Germany, to characterize the clinical features and medical treatment of CH. Student's t-test, the Chi-square test, and Fisher's exact test were used for statistical analysis.
Most (77.6%) were men and had episodic (74.7%) rather than chronic (16.7%) CH. Nine percent were newly diagnosed, with no established pattern. Mean age of onset was 36.9 years for both men and women. Strictly unilateral pain, albeit changing sides between attacks, was seen in 97.2%. Seventy-nine percent were always strictly unilateral and 2.8% were bilateral, remaining predominantly one-sided but radiating to the contralateral side. Pain was usually sharp (61.8%) or pulsating (31.3%), and usually lasted 45-180 minutes (67.9%). Twenty-four percent experienced attacks of 2-45 minutes in duration and, in 7.3%, it lasted longer than 3 hours. Cranial autonomic features, including ptosis, miosis, ipsilateral facial sweating, nasal congestion and/or rhinorrhea were present in almost all (98.8%), with many experiencing restlessness during the attack (67.9%) and photophobia and phonophobia (61.2%). Twenty-three percent experienced migrainous aura of fortification spectra, tunnel vision, hemiparesis, hemisensory symptoms, dysarthria, or dysphasia, and physical activity worsened the pain in 21.7%. Men and women shared these clinical characteristics.
Alcohol consumption was more frequent in patients with episodic than chronic CH and, in 53.5%, alcohol (red wine [70.5%] or beer [23%]) triggered an attack, usually within 1 hour (65.2%), with a shorter latency in men than women. Sixty-six percent were current smokers, and 29% had never smoked.
Acute abortive therapy most often comprised triptans (77.6%) and oxygen (71.1%), with 71.7% and 76.6% experiencing relief, respectively. Ergots (32.1%) and lidocaine nasal spray (22.8%) were used less frequently, and almost 60% used unproven medication, including non-steroidals, caffeine, and opioids. Prophylactic medication was used in 84.6%; usually verapamil (70.3%, with 65.3% efficacy) or corticosteroids (57.7%, with 73.2% efficacy). Lithium was effective in 37%, but valproic acid in only 20%. Once properly recognized and diagnosed, appropriate treatment is usually effective for CH.
More recently described treatments for CH include hypothalamic stimulation, where 13 of 16 intractable CH patients were pain-free or almost so, with no persistent side effects, following 23 months of follow-up, and the remaining 3 were improved (Neurology 2006;67;150-2). Among 53 CH patients who had experimented with psilocybin or lysergic acid diethylamide (LSD), 22 of 26 noted that psilocybin aborted attacks, 25 of 48 noted that it terminated the cluster period, and 18 of 19 reported that it extended their remission period (Neurology 2006,;66;1920-2). Cluster period termination was reported in 7 of 8 LSD users, and extended remission in 4 of 5. Clozapine, testosterone, and pramipexole have also been reportedly successful. Clearly, more research is needed to determine the most effective and safe treatments for this disabling and common disorder.