Cluster headache: Myths and the evidence

Increased suicidality in patients with cluster headache

OBJECTIVE

To investigate suicidality related to cluster headache and factors associated with increased suicidality in cluster headache patients.

METHODS

In this multicenter study, 193 cluster headache patients were recruited between September 2016 and August 2018. Patients were asked about their suicidality during and between attacks, specifically about passive suicidal ideation, active suicidal ideation, suicide plan, and suicide attempt. Univariable and multivariable logistic regression analyses were performed to evaluate the factors associated with high ictal suicidality (sum of positive response ≥ 2). Patients were followed up when they were in the between-bouts period.

RESULTS

A total of 175 cluster headache patients in the in-bout period were included in this study. Passive suicidal ideation, active suicidal ideation, suicidal planning, and suicidal attempt were reported by 111 (64.2%), 62 (35.8%), 10 (5.8%), and four (2.3%) patients during attacks; seven (4.0%), six (3.5%), five (2.9%) and two (1.2%) patients interictally; and none (0%), one (1.9%), one (1.9%), and none (0%) among patients in the between-bouts period. Factors associated with high ictal suicidality were longer disease duration, the Headache Impact Test score, and the Patient Health Question-9 score (multivariable OR = 1.90 per 10-year increase in disease duration, 95% CI = 1.18-3.05, p = 0.008; multivariable OR = 3.19 per 10-point increase in HIT-6, 95% CI = 1.73-5.87, p < 0.001; multivariable OR = 2.11 per 10-point increase in PHQ-9, 95% CI = 1.13-3.95, p = 0.020, respectively).

CONCLUSIONS

Cluster headache attack carries a high suicidality compared to the interictal or between-bouts state. An intensive treatment to reduce cluster headache burden may be helpful to alleviate suicide risk in cluster headache patients.

Personality disorders in cluster headache: a study using the Millon Clinical Multiaxial Inventory-III

A great deal of studies suggests that cluster headache (CH) patients are usually comorbid to anxiety-mood spectrum disorders and psychopathological symptoms; however, the personality profiles reported in the literature strictly depend on type of assessment used. Psychiatric comorbidities have been extensively studied in migraine and they are recognized to represent a major risk factor associated with poorer outcome, playing a role in the headache chronification process at once as cause and consequence of it. By contrast the incidence and role of psychopathological aspects in CH is still not clarified, insufficiently explored as the striking severity of such a physical pain apparently leaves no room to psychological explanations. The aim of the present study is to describe psychopathological aspects of CH patients by means of the Millon Clinical Multiaxial Inventory-III (MCMI-III), a psychological assessment tool compatible to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) that correlates personality disorders (PDs) and clinical syndromes. We included all consecutive inward patients with CH between January 2014 and December 2016. Patients were evaluated using the MCMI-III a validated inventory assessing 14 PDs Scales (coordinate with DSM-IV Axis II disorders) and ten Clinical Syndrome Scales (coordinate with DSM-IV Axis I disorders). Twenty-six CH patients (24 chronic CH) were tested. Personality disorders were present in 92% of the patients. The most frequent PDs were: obsessive-compulsive (30.8%), histrionic (26.9%), narcissistic (11.5%), paranoid (11.5%) and avoidant (11.5%). According to the MCMI-III, patients with CH showed a high prevalence of personality disorders (Axis II-DSM-IV). PDs in CH patients can play an important role in determining CH course toward chronification. These preliminary results suggest that behavioral treatments can find room to support more conventional drug and neurostimulation therapies in these patients. In addition, the very high prevalence of PDs in our patients suggests that CH could in some cases be considered among the spectrum of somatoform and pain syndromes in patients with PDs.

Suicide in primary headaches in 48 countries: A physician-survey based study

Aim To investigate the relationship between primary headache types and accomplished or attempted suicide in countries from all world regions. Methods Data were obtained using a questionnaire about suicide due to headache in a face-to-face interview with 203 physicians with expertise in headaches. They came from 48 countries, and from all continents. Results Primary headaches cause one suicide per 1,000,000 population each year (1% of the suicide rate due to all causes). Cluster headache and migraines account for 70-80% of them. Suicide attempts are 10 times more frequent than accomplished suicides. Cluster headache poses more risk than migraine. This risk is not often acknowledged, and is increased if there is previous psychiatric history. More than half of the physicians interviewed think it could be reduced with a more aggressive treatment of headaches. Conclusions Cluster headache and migraine are not always benign, and are the cause of the majority of suicides due to headache.

Illicit drug use in cluster headache patients and in the general population: a comparative cross-sectional survey

BACKGROUND

The rate of illicit drug use in cluster headache (CH) patients is unknown.

METHODS

Two hundred and ten CH patients (162 males and 48 females) attending two headache clinics provided information about their lifetime use (once or more in their lifetime, LTU), recent use (once or more in the past year, RU), and current use (once or more in the past 30 days, CU) of illicit drugs. General population data (IPSAD®Italia2007-2008) served as the control group.

RESULTS

LTU of each illicit drug but hallucinogens, RU of cannabis, cocaine, amphetamines and ecstasy, and CU of cannabis and cocaine were significantly higher in the male CH patients than in the general population, whereas no difference was found between the CH women and the controls. In the CH group, 28.5% of patients reported having used illicit drugs for the first time after CH onset and 71.5% before CH onset. Compared with the controls, the male CH group showed a greater prevalence both of lifetime sustained intensive use of any illicit drug and of current intensive use of cannabis.

CONCLUSION

The results of this study indicate that male CH patients are prone to overindulge in illicit drug use. This finding possibly reflects a common biological susceptibility that predisposes these subjects to CH and to addictive behaviour.