Trigeminal autonomic cephalalgias. Part 1: cluster headache

Pain Part 9: Trigeminal Autonomic Cephalalgias

The trigeminal autonomic cephalalgias are a group of rare, highly disabling, primary headache syndromes distinctly characterized by the unilaterality of their attacks and presence of cranial autonomic symptoms. Although pain is often localized to the peri-orbital and temporal regions, it is not uncommon for pain to radiate to tooth-bearing areas and mimic toothache or jaw pain. Hence, dental practitioners should be aware of these syndromes to enable appropriate referral and avoid unnecessary, and often irreversible, dental treatments. Many dentists will not have heard of these conditions but must remain vigilant, and ensure that they are not confused with trigeminal neuralgia, so that their patients are appropriately advised and referred. Clinical relevance: The dental practitioners may be the first line of healthcare providers consulted by these patients in the hope of obtaining pain relief. Lack of familiarity with an uncommon condition may lead to poor patient management.

[Therapeuetic aspects of cluster headache in the practical clinical site]

The therapeutic procedures of cluster headache begin from the precise diagnose. Because cluster headache is usually accompanied with teeth pain and/or neck pain, some patients aren't able to consult adequate medical institutions. In this lecture I showed the some male and female patients as examples. The female patient was suffered from menstruation related migraine in her period of cluster headache. From the view point of treatment, preventive medicines are essential. They not just reduce severity and also improve the length of headache-period. Suitable preventive medicines may avoid the whole severe attacks. We reported therapeutic experiences of valproate, gabapentin and amitriptyline with verapamil in 2010 at general meeting of Societas Neurologica Japonica. Steroids are not indispensable. As for triptans rapid-type one are usually used. If the attacks are severe, sumatriptan subcutaneous injection kit (SSI) needs to be introduced. The expert nurses who are skilled in the procedures of SSI improve both patients' adherence and therapeutic efficiency. We held a first educational meeting of SSI in Tokyo 2012. Because cluster headache is formidable, the integrated therapy which is composed of precise diagnosis, preventive medicine and adequate medicines for headache attacks is essential and needed.

Clinical course of patients with episodic cluster headache treated with corticosteroids inproximity to the sphenopalatine ganglion: a preliminary study of 23 patients

OBJECTIVE

A study is made of the clinical course of patients with episodic cluster headache following the injection of corticosteroids in the proximity of the sphenopalatine ganglion of the affected side.

STUDY DESIGN

A retrospective observation study was made corresponding to the period between 2006 and 2010. Patients with episodic cluster headache received corticosteroid infiltrations in the vicinity of the sphenopalatine ganglion. Data were collected to assess the clinical course, quantifying pain intensity and quality of life. A total of 23 patients (11 women and 12 men) with a mean age of 50.4 years (range 25-65) were included. Forty percent of the patients had undergone dental extractions in the quadrant affected by the pain, before the development of episodic cluster headache, and 37.8% underwent extractions in the same quadrant after appearance of the headache.

RESULTS

Most of the patients suffered 1-3 attacks a day, with a duration of pain of between 31-90 minutes. The mean pain intensity score during the attacks at the time of the first visit was 8.8 (range 6-10), versus 5.4 (range 3-9) one week after the first corticosteroid injection. On the first visit, 86.9% of the patients reported unbearable pain, versus 21.7% after one week, and a single patient after one month.

CONCLUSIONS

The evolution of episodic cluster headache is unpredictable and variable, though corticosteroid administration clearly reduces the attacks and their duration.

Evidence-based interventional pain medicine according to clinical diagnoses. 2. Cluster headache

Cluster headache is a strictly unilateral headache that is associated with ipsilateral cranial autonomic symptoms and usually has a circadian and circannual pattern. Prevalence is estimated at 0.5 to 1.0/1,000. The diagnosis of cluster headache is made based on the patient's case history. There are two main clinical patterns of cluster headache: the episodic and the chronic. Episodic is the most common pattern of cluster headache. It occurs in periods lasting 7 days to 1 year and is separated by at least a 1-month pain-free interval. The attacks in the chronic form occur for more than 1 year without remission periods or with remission periods lasting less than 1 month. Conservative therapy consists of abortive and preventative remedies. Ergotamines and sumatriptan injections, sublingual ergotamine tartrate administration, and oxygen inhalation are effective abortive therapies. Verapamil is an effective and the safest prophylactic remedy. When pharmacological and oxygen therapies fail, interventional pain treatment may be considered. The effectiveness of radiofrequency treatment of the ganglion pterygopalatinum and of occipital nerve stimulation is only evaluated in observational studies, resulting in a 2 C+ recommendation. In conclusion, the primary treatment is medication. Radiofrequency treatment of the ganglion pterygopalatinum should be considered in patients who are resistant to conservative pain therapy. In patients with cluster headache refractory to all other treatments, occipital nerve stimulation may be considered, preferably within the context of a clinical study.

Cluster headache with Brugada electrocardiogram pattern: a case report

Agents including the effect on sodium channel are restricted in patients with Brugada electrocardiogram (ECG) pattern or Brugada syndrome. On the other hand, many therapeutic agents for cluster headache (CH) block sodium channel. After recommended therapies without sodium channel blocking effect were failed in a 40-year-old male with CH whose ECG shows Brugada ECG pattern, clonazepam and codein phosphate, which are exceptional treatments for CH, were effective for severe unilateral orbital pain.