Diagnosis and treatment of cluster headache

Propofol and alfentanil in treatment of a patient with episodic cluster headache

Introduction:

Cluster headache is a severe hemifacial pain with concomitant symptoms such as lacrimation, conjunctival congestion, and nasal discharge. Peripheral (to be a spectrum of trigeminal autonomic cephalgia) and central (hypothalamus) disorders have been suggested to be involved. Several modalities have been recommended to prevent or alleviate this devastating headache.

Case Presentation:

In this case report, we presented a young man with an acute cluster headache who responded dramatically to the treatment with propofol and alfentanil.

Conclusions:

Propofol and alfentanil combination can be considered as a treatment approach in the attack phase of cluster headache.

LONG-TERM RESULTS OF RADIOSURGERY FOR REFRACTORY CLUSTER HEADACHE

OBJECTIVE

Medically refractory cluster headache (CH) is a debilitating condition for which few surgical modalities have proven effective. Previous reports involving short-term follow-up of CH patients have reported modest degrees of pain relief after radiosurgery of the trigeminal nerve ipsilateral to symptom onset. With the recent success of deep brain stimulation as a surgical modality for these patients, it becomes imperative for the long-term risks and benefits of radiosurgery to be more extensively delineated. To address this issue, we present our findings from the largest retrospective series of patients undergoing radiosurgery for CH with extended follow-up periods.

METHODS

Between 1997 and 2001, 10 patients with CH underwent gamma knife radiosurgery at our institution. All patients fulfilled clinical criteria for treatment, including complete resistance to pharmacotherapy (usually methysergide, verapamil, and lithium), pain primarily localized to the ophthalmic division of the trigeminal nerve, and psychological stability. The mean age at radiosurgery was 40.3 years (range, 26–62 yr), and the average CH duration was 11.3 years (range, 2–21 yr). Patients received 75 Gy to the 100% isodose line delivered to the most proximal part of the trigeminal nerve where the 50% isodose line was outside the brainstem (4-mm collimator), with a mean follow-up period of 39.7 months (range, 5–88 mo). Pain relief was defined as excellent (free of CH with minimal or no medications), good (50% reduction of CH severity and frequency with medications), fair (25% reduction of CH severity and frequency with medications), or poor (less than 25% reduction of CH severity and frequency with medications).

RESULTS

After radiosurgery, pain relief was poor in nine patients and fair in one patient. Six patients with poor to fair relief initially experienced excellent to good relief (range, 2 wk–2 yr after treatment) before regressing. Five patients (50%) experienced trigeminal nerve dysfunction, manifesting predominantly as facial numbness after treatment.

CONCLUSION

Although some patients may experience short-term pain relief, none had relief sustainable for longer than 2 years. The results from this series indicate that radiosurgery of the trigeminal nerve does not provide long-term pain relief for medically refractory CH.

Cluster headache

Cluster headache is a relatively rare episodic headache disorder.Although traditionally it is believed to be a male-related disorder,the sex ratios are changing toward a more even balance. The disorder is characterized by bouts of daily headaches with pain-free remissions for extended times. Though attacks are brief, they are severe and typically are associated with autonomic symptoms. Medical therapies are the mainstay of treatment, with the goal being prevention of headaches in a cycle. Acute therapies, although effective, may be limited in usefulness because of attack frequency. Intractable cases may benefit from histamine desensitization and surgical treatments.

Stimulation of the Posterior Hypothalamus for Treatment of Chronic Intractable Cluster Headaches: First Reported Series

OBJECTIVE

To describe the results of deep brain stimulation of the ipsilateral posterior hypothalamus for the treatment of drug-resistant chronic cluster headaches (CHs). A technique for electrode placement is reported.

METHODS

Because recent functional studies suggested hypothalamic dysfunction as the cause of CH bouts, we explored the therapeutic effectiveness of posterior hypothalamic stimulation for the treatment of CHs. Five patients with intractable chronic CHs were treated with long-term, high-frequency, electrical stimulation of the posterior hypothalamus. Electrodes were stereotactically implanted in the following position: 3 mm behind the midcommissural point, 5 mm below the midcommissural point, and 2 mm lateral to the midline.

RESULTS

Since this treatment, all five patients continue to be pain-free after 2 to 22 months of follow-up monitoring. Two of the five patients have remained pain-free without any medication, whereas three of the five required low doses of methysergide (two patients) or verapamil (one patient). No adverse side effects of chronic, high-frequency, hypothalamic stimulation have been observed, and we have not encountered any acute complications resulting from the implant procedure. There have been no tolerance phenomena.

CONCLUSION

These preliminary results indicate a role for posterior hypothalamic stimulation, which was demonstrated to be safe and effective, in the treatment of drug-resistant chronic CHs. These data point to a central pathogenesis for chronic CHs.

Sensory and affective components of orofacial pain: is it all in your brain?

In this paper, we shall review several chronic orofacial pain conditions with emphasis on those that are essentially refractory to treatment. We shall present a review of current and past literature that describes the various pain phenomena as well as their underlying central mechanisms. New data concerning refractory pain will be used to underscore the importance of central processing of pain, with particular emphasis on neuropsychological and cognitive function and capacity that may play important roles in pain processing and maintenance of the pain state. Further, neurophysiological data showing that the anterior cingulate cortex (ACC) and other structures in the brain may play key roles in modulation of chronic pain will also be discussed. Although peripheral triggering events surely play an important role in initiating pain, the development of chronic and, in particular, refractory pain may depend on changes or malfunctions in the central nervous system. These changes may be quite subtle and require sophisticated approaches, such as functional MRI, to study them, as is now being done. New findings obtained therefore may lead to more rational and reliable treatment for orofacial pain.

Ethical considerations in cluster headache research

Cluster headache is the most painful of the primary headache disorders and elucidating pathophysiology and treatment for this disorder is crucial. There is justification for studying attacks untreated, and even for precipitating these attacks. Placebo-controlled studies should only be undertaken for regulatory purposes; otherwise, active control should be used.

Relief of cluster headache and cranial neuralgias. Promising prophylactic and symptomatic treatments

When a patient presents with persistently unilateral head or face pain, cluster headache and trigeminal neuralgia should be considered. Diagnosis is based on the patient's history; anatomical studies are performed only to rule out problems other than tumor or stroke. A patient who presents with pain in the pharynx, tonsils, and ear--particularly if it is initiated by swallowing, yawning, or eating--may have glossopharyngeal neuralgia. Treatment with carbamazepine is indicated; if the patient does not respond to this drug, the diagnosis is doubtful. Several effective treatments are available for these conditions. Oxygen, drug therapy, or surgery may be indicated depending on the course of the disease.

Episodic cluster headache in a community: clinical features and treatment

OBJECTIVE

To study the clinical features and treatment given to episodic cluster headache patients in the Calgary region.

PATIENTS

Fifty-one (51) patients who responded to a media campaign, had previously been diagnosed by their family physicians, and who met International Headache Society (IHS) criteria for episodic cluster headache, formed the population for this study.

METHODS

The media campaign consisted of newspaper advertisements and radio publicity including physician interviews and talk shows. Patients were required to complete by 200-item questionnaire detailing clinical features and treatment of their cluster headache syndrome. Each patient was also interviewed by our research nurse for clarification and proper completion of questionnaire.

RESULTS

Fifty-one percent (51%) of our patients had short headache attacks lasting one hour or less. Almost one-half (45%) had three or four attacks per 24 hour period. Eighty-six percent (86%) had been referred to a neurologist. Sixty-nine percent (69%) had never used oxygen, but of those who had, one-half were still using it. Sumatriptan by injection had been tried by 26% of patients and of these, 93% considered it effective. Subcutaneous dihydroergotamine had been tried by 8%. For prophylaxis, 41% had tried methysergide, 31% prednisone, and 4% verapamil. Many patients had been prescribed migraine prophylactic drugs which are ineffective for cluster headache, and some had also undergone dental procedures or nasal and sinus surgeries.

CONCLUSIONS

Many cluster headache patients had not, to their knowledge, been prescribed or used the best symptomatic and prophylactic treatments for cluster headache. This should be addressed through educational programs and through making up-to-date information on the treatment of cluster headache readily available to physicians and patients.

Cluster-like signs and symptoms respond to myofascial/craniomandibular treatment: a report of two cases

Two cases with pain profiles characteristic of cluster-like headache, both within and outside the trigeminal system, are reported. One male patient would typically awaken from sleep with severe unilateral temporal head pain and autonomic signs of ipsilateral lacrimation and nasal congestion. A female patient exhibited severe unilateral boring temporal and suboccipital head pain with associated ipsilateral lacrimation and rhinorrhea. In addition, both patients presented with signs and symptoms of masticatory and/or cervical disorders. These two cases illustrate possible treatment alternatives, as well as possible influences from cervical and masticatory structures in the development of cluster or cluster-like headache.

Headaches in the elderly

Headache prevalence and etiology vary dramatically with age. The prevalence of primary headache disorders, such as migraine and cluster, declines with age, while the prevalence of secondary headache disorders, such as temporal arteritis and mass lesions, increases. In evaluating elderly patients with new onset of headache, a high index of suspicion for organic disease is required. Headache symptomatology also varies with age. For example, migraine may evolve into a pattern of chronic daily headache, or auras may occur in the absence of headache (late-life migraine accompaniments). A careful longitudinal headache history is therefore important. Headache management is also influenced by age. Elderly people are more susceptible to medication side effects and are often treated with several drugs. Medications may cause headaches and drug interactions may complicate therapy. For these reasons, age of onset and duration of illness are critical headache features that guide the subsequent approach to diagnosis and treatment.