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Van Houtte J, Vandenbussche N, Derom E, Schoenen J, Versijpt J, Paemeleire K. Oxygen as an abortive therapy in cluster headache: a narrative review and clinical practice aspects. Acta Neurol Belg 2024:10.1007/s13760-024-02506-z. [PMID: 38498266 DOI: 10.1007/s13760-024-02506-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/08/2024] [Indexed: 03/20/2024]
Abstract
Cluster headache (International Classification of Headache Disorders third edition, ICHD-3 3.1) is a primary headache disorder affecting around 0.12% of individuals. It is characterized by severe headache attacks causing significant negative impact on the lives of patients. While administration of 100% oxygen is considered to be the first-choice acute treatment, undertreatment also exists. Reasons for undertreatment may entail problems with the correct prescription of oxygen, reimbursement issues or the practical implementation of home oxygen therapy. The aim of this manuscript is to review the scientific evidence on oxygen therapy for cluster headache and provide a practical guidance for both physicians and patients to optimize its use in an acute setting. The current evidence of the administration of 100% oxygen as a safe and effective treatment for cluster headache is strong. Based on several clinical trials and surveys, the recommended flow rates range between 12 and 15 L/min via a non-rebreathing mask, for at least fifteen minutes. The frequency of cluster headache attacks and thus the need for acute treatment can be very high. Fortunately, the Belgian social security system provides a full and lifetime reimbursement of oxygen therapy for cluster headache if the diagnosis and the need for this therapy has been certified by a neurologist, neurosurgeon or neuropsychiatrist.
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Affiliation(s)
- Julie Van Houtte
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Nicolas Vandenbussche
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Eric Derom
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jean Schoenen
- Headache Research Unit, Department of Neurology, University of Liège, Liège, Belgium
| | - Jan Versijpt
- Department of Neurology, Brussels University Hospital, Jette, Belgium
| | - Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Hagen K. One-year prevalence of cluster headache, hemicrania continua, paroxysmal hemicrania and SUNCT in Norway: a population-based nationwide registry study. J Headache Pain 2024; 25:30. [PMID: 38443787 PMCID: PMC10916002 DOI: 10.1186/s10194-024-01738-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND There is lack of population-based studies evaluating the prevalence of paroxysmal hemicrania, hemicrania continua and short-lasting unilateral neuralgiform headache attacks. OBJECTIVES The aim of this study was to investigate the gender-specific 1-year prevalence of cluster headache, paroxysmal hemicrania, hemicrania continua, and short-lasting unilateral neuralgiform headache attacks. METHODS A nationwide study was conducted from January 1 2022 and December 31 2022 by linking diagnostic codes from Norwegian Patient Registry and prescription of relevant drugs from Norwegian Prescription Database on an individual basis. The 1-year prevalence with 95% confidence intervals (CI) of cluster headache, paroxysmal hemicrania, hemicrania continua and short-lasting unilateral neuralgiform headache attacks are estimated based on the combination of diagnostic codes, prescription of drugs and corresponding reimbursement codes. RESULTS Among 4,316,747 individuals aged ≥ 18 years, the 1-year prevalence per 100,000 was 14.6 (95% CI 13.5-15.8) for cluster headache, 2.2 (95% CI 1.8-2.7) for hemicrania continua, 1.4 (95% CI 1.0-1.8) for paroxysmal hemicrania, and 1.2 (95% CI 0.8-1.4) for short-lasting unilateral neuralgiform headache attacks. For all the trigeminal autonomic cephalalgies, cluster headache included, the prevalence was higher for women than men. CONCLUSIONS In this nationwide register-based study, we found a 1-year prevalence per 100,100 of 14.6 for cluster headache, 2.2 for hemicranias continua, 1.4 for paroxysmal hemicranias, and 1.2 for short-lasting unilateral neuralgiform headache attacks. This is the first study reporting higher prevalence of cluster headache for women than men.
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Affiliation(s)
- Knut Hagen
- Department of Medical Quality Registries and Clinical Research Unit, St. Olav's University Hospital, Trondheim, 7006, Norway.
- Department of Neuromedicine and Movement Science, NorHEAD-Norwegian Centre for Headache Research, Norwegian University of Science and Technology, Trondheim, Norway.
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Lamas Pérez R, Millán-Vázquez M, González-Oria C. Efficacy and safety of galcanezumab as chronic cluster headache preventive treatment under real world conditions: Observational prospective study. Cephalalgia 2024; 44:3331024231226181. [PMID: 38501892 DOI: 10.1177/03331024231226181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Calcitonin gene-related peptide has shown to play a central role in cluster headache (CH) pathophysiology. A clinical trial with galcanezumab was carried out in chronic cluster headache (CCH) but did not meet its primay endpoint. However, its off-label use in patients with CCH refractory to other therapies could be considered. We aimed to asses the efficacy and safety of galcanezumab as CCH preventive treatment in a real-life setting. METHODS An observational study was conducted. Patients with CCH who received at least one dose of 240 mg of galcanezumab. RESULTS Twenty-one patients who tried a mean of 6.3 ± 1.9 preventive therapies, including onabotulinumtoxinA in 90.5%. At baseline, the median of frequency was 60 (37.5-105) monthly attacks with 10 (8.3-10) points in pain intensity (Numerical Rating Scale). After one month, the frequency decreased to 31 (10.5-45) (p = 0.003) with 8.5 (8-9.5) intensity (p = 0.007); 10 (47.6%) patients were 50% responders of whom four (19%) were 75% responders. Of the 15 patients with 3 months of follow-up, seven (46.6%) reduced their frequency by 50% and four (26.6%) by 75%, with 40 (10-60) monthly attacks (p = 0.07) and pain intensity of 8 (5-10) (p = 0.026). Some 52% patients experienced adverse events, mostly mild. CONCLUSIONS In our cohort of refractory CCH, galcanezumab was effective in almost 50% of patients. This finding supports individual off-label treatment attempts.
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Affiliation(s)
- Raquel Lamas Pérez
- Headache Unit, Neurology Department, Virgen del Rocío University Hospital, Seville, Spain
| | - Manuel Millán-Vázquez
- Headache Unit, Neurology Department, Virgen del Rocío University Hospital, Seville, Spain
| | - Carmen González-Oria
- Headache Unit, Neurology Department, Virgen del Rocío University Hospital, Seville, Spain
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Cho S, Kim BK, Chu MK, Moon HS, Lee MJ, Bae DW, Han J, Lee SH, Cho SJ. Efficacy of Oxygen Treatment Using Home Oxygen Concentrators for the Treatment of Cluster Headaches: A Randomized, Crossover, Multicenter Study. J Clin Neurol 2024; 20:78-85. [PMID: 38179635 PMCID: PMC10782089 DOI: 10.3988/jcn.2023.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/07/2023] [Accepted: 05/30/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Oxygen treatment is the first-line acute treatment for cluster headaches (CHs), but this can be impeded by insurance coverage and oxygen-tank maintenance. Oxygen concentrators filter nitrogen from ambient air to produce oxygen-rich gas, and can therefore be an alternative to conventional oxygen therapy using a tank. We investigated the effectiveness and safety of using two home oxygen concentrators and compared them with using oral zolmitriptan for the acute treatment of CHs. METHODS Forty patients with episodic CHs in an active cluster period were enrolled in this randomized, crossover, multicenter study. Two attacks during the cluster period were treated using oxygen delivered by connecting two home oxygen concentrators, whereas the other two attacks were treated using oral zolmitriptan (5 mg) in a random sequence. The primary endpoint was substantial pain reduction (0 or 1 on a five-point rating scale from 0 to 4 points) at 15 min after treatment. RESULTS In total, 125 attacks among 32 patients were randomized and treated (63 attacks using oxygen and 62 using zolmitriptan) according to the study protocol. More attacks treated using oxygen reached the primary endpoint than did those treated using zolmitriptan (31.7% [20/63] vs. 12.9% [8/62], p=0.013). After 30 min, 57.1% of the patients who received oxygen and 38.7% who received zolmitriptan reported pain relief (p=0.082). All patients treated using oxygen reported an improvement in pain, and 61.3% preferred oxygen while only 9.7% preferred zolmitriptan. No adverse events occurred during the oxygen treatment. CONCLUSIONS Oxygen treatment administered using two home oxygen concentrators resulted in better pain relief than oral zolmitriptan in patients with episodic CHs. Our results suggest that home oxygen concentrators are capable of efficiently supplying oxygen in a similar manner to using an oxygen tank.
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Affiliation(s)
- Soohyun Cho
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Heui-Soo Moon
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dae-Woong Bae
- Department of Neurology, St Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Junhee Han
- Department of Statistics, Hallym University, Chuncheon, Korea
| | - Sang-Hwa Lee
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea.
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
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Gordon A, Roe T, Villar-Martínez MD, Moreno-Ajona D, Goadsby PJ, Hoffmann J. Effectiveness and safety profile of greater occipital nerve blockade in cluster headache: a systematic review. J Neurol Neurosurg Psychiatry 2023; 95:73-85. [PMID: 36948579 DOI: 10.1136/jnnp-2023-331066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/07/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Greater occipital nerve (GON) blockade is a short-term preventive therapy for cluster headache (CH). We conducted a systematic review to evaluate the effectiveness and safety of GON blockade in patients with CH. METHODS On 23 October 2020, we searched MEDLINE, Embase, Embase Classic, PsycINFO, CINAHL, CENTRAL and Web of Science databases from their inception date. Studies included participants with a CH diagnosis who received corticosteroid and local anaesthetic suboccipital region injections. Outcomes were change in the frequency/severity/duration of attacks; proportion of participants responding to treatment, time to attack freedom from an attack, change in attack bout length and/or the presence of adverse effects after GON blockade. Risk of bias was assessed with the Cochrane Risk of Bias V.2.0 (RoB2)/Risk of Bias in Non-randomized Studies - of Interventions (ROBINS- I) tools and a specific tool for case reports/series. RESULTS Two RCTs, eight prospective and eight retrospective studies, and four case reports were included in the narrative synthesis. Every effectiveness study found a significant response in one or more of frequency/severity/duration of individual attacks or proportion of patients responding to treatment (47.8%-100.0%). There were five instances of potentially irreversible adverse effects. A higher injectate volume and use of concurrent prophylaxis may be associated with an increased likelihood of response. Methylprednisolone may have the best safety profile of available corticosteroids. DISCUSSION GON blockade is safe and effective for CH prevention. Higher injectate volumes may improve likelihood of response, and the likelihood of serious adverse events may be reduced by using methylprednisolone. PROSPERO REGISTRATION NUMBER CRD42020208435.
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Affiliation(s)
- Alexander Gordon
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Thomas Roe
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - María Dolores Villar-Martínez
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - David Moreno-Ajona
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Peter J Goadsby
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
| | - Jan Hoffmann
- Wolfson Centre for Age-Related Diseases, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR-Wellcome Trust King's Clinical Research Facility/SLaM Biomedical Research Centre, King's College Hospital, London, UK
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Cotton S, Andrews JS, Nichols RM, Jackson J, Tockhorn-Heidenreich A, Milligan G, Martinez JM. Clinical characteristics and treatment patterns of patients with episodic cluster headache: results from the United States, United Kingdom and Germany. Curr Med Res Opin 2023; 39:1637-1647. [PMID: 37615206 DOI: 10.1080/03007995.2023.2237741] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To describe clinical characteristics and regional treatment patterns of episodic cluster headache (CH). METHODS A point-in-time survey of physicians and their patients with CH was conducted in the United States, United Kingdom and Germany in 2017. RESULTS Overall, 1012 patients with episodic CH were analyzed. Demographic and clinical findings were generally consistent across regions. Most patients were men (66.6%) and the mean age was 40.9 years. The greatest proportion of patients (38.3%) had ≤1 attack per day. The mean number of attacks per day (APD) was 2.4 and mean number of cluster periods per year was 2.6; the mean cluster period duration was 30.8 days. Most patients (69.3%) did not report a specific or predicable time when cluster periods occurred. Acute treatment was prescribed for 47.6% of patients, 10.3% of patients received preventive treatment, and 37.9% of patients received combined acute and preventive treatment; 4.2% of patients were not receiving treatment. Frequently prescribed acute treatments were sumatriptan, oxygen, and zolmitriptan; oxygen use varied considerably across countries and was prescribed least often in the United States. Frequently prescribed preventive treatments were verapamil, topiramate, and lithium. Lack of efficacy and tolerability were the most common reasons for discontinuing preventive treatment. CONCLUSIONS We observed high use of acute treatments, but only half of patients used preventive treatments despite experiencing several cluster periods per year with multiple cluster APD. Further studies about the need for and benefits of preventive treatment for episodic CH are warranted.
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Rodriguez-Leyva I, Velez-Jimenez MK, García S, Nader-Kawachi JA, Martínez-Mayorga AP, Melo-Carrillo A, Juárez-Jimenez H, Martinez-Gurrola M, Gudiño-Castelazo M, Chiquete E, Villareal-Careaga J, Marfil A, Uribe-Jaimes PD, Vargas-García RD, Collado-Ortiz MA, San-Juan D. Cluster headache: state of the art in treatment. FRONTIERS IN PAIN RESEARCH 2023; 4:1265540. [PMID: 37965210 PMCID: PMC10641784 DOI: 10.3389/fpain.2023.1265540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/29/2023] [Indexed: 11/16/2023] Open
Abstract
Cluster headache (CH) is the most common and devastating autonomic headache with multiple and recent advances in treatment. However, it usually goes unrecognized and is found to have a delayed and inappropriate treatment. This paper aims to review the current therapeutic options for patients with CH. We conducted a narrative literature review on the treatments available for this condition using the American Academy of Neurology (AAN) classification of therapeutic evidence. We found effective and safe pharmacological and non-pharmacological therapies with heterogeneity of clinical trial designs for patients with CH, and they are divided into three phases, namely, transitional, acute, and preventive interventions. Prednisone (A) is the most studied treatment in the transitional phase; acute attacks are treated using triptans (A), oxygen (A), and non-invasive transcutaneous vagal nerve stimulation (A). Verapamil (A) and monoclonal antibodies (possible A) are considered the first options in preventive treatments, followed by multiple pharmacological and non-pharmacological options in prophylactic treatments. In conclusion, numerous effective and safe treatments are available in treating patients with episodic, chronic, and pharmacoresistant CH according to the clinical profile of each patient.
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Affiliation(s)
- Ildefonso Rodriguez-Leyva
- Department of Neurology, Faculty of Medicine, Central Hospital “Dr. Ignacio Morones Prieto,”Universidad Autónoma de San Luis Potosi, San Luis Potosi, Mexico
| | | | - Silvia García
- Clinical Research Department, Centro Médico Nacional “20 de Noviembre,” ISSSTE, Mexico City, Mexico
| | | | | | - Agustín Melo-Carrillo
- Anesthesia Department, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | | | | | | | - Erwin Chiquete
- Department of Neurology and Psychiatry, National Institute of Medical Science and Nutrition “Salvador Zubirán,”Mexico City, Mexico
| | | | - Alejandro Marfil
- Headache and Chronic Pain Clinic, Neurology Service, Hospital Universitario “Dr. J. E. González” of the Universidad Autónoma de Nuevo Leon, Monterrey, Mexico
| | | | | | | | - Daniel San-Juan
- Epilepsy Clinic of the National Institute of Neurology and Neurosurgery Manuel Velazco Suarez, Mexico City, Mexico
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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] [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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Lund NLT, Petersen AS, Fronczek R, Tfelt-Hansen J, Belin AC, Meisingset T, Tronvik E, Steinberg A, Gaul C, Jensen RH. Current treatment options for cluster headache: limitations and the unmet need for better and specific treatments-a consensus article. J Headache Pain 2023; 24:121. [PMID: 37667192 PMCID: PMC10476341 DOI: 10.1186/s10194-023-01660-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/22/2023] [Indexed: 09/06/2023] Open
Abstract
AIM Treatment for cluster headache is currently based on a trial-and-error approach. The available preventive treatment is unspecific and based on few and small studies not adhering to modern standards. Therefore, the authors collaborated to discuss acute and preventive treatment in cluster headache, addressing the unmet need of safe and tolerable preventive medication from the perspectives of people with cluster headache and society, headache specialist and cardiologist. FINDINGS The impact of cluster headache on personal life is substantial. Mean annual direct and indirect costs of cluster headache are more than 11,000 Euros per patient. For acute treatment, the main problems are treatment response, availability, costs and, for triptans, contraindications and the maximum use allowed. Intermediate treatment with steroids and greater occipital nerve blocks are effective but cannot be used continuously. Preventive treatment is sparsely studied and overall limited by relatively low efficacy and side effects. Neurostimulation is a relevant option for treatment-refractory chronic patients. From a cardiologist's perspective use of verapamil and triptans may be worrisome and regular follow-up is essential when using verapamil and lithium. CONCLUSION We find that there is a great and unmet need to pursue novel and targeted preventive modalities to suppress the horrific pain attacks for people with cluster headache.
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Affiliation(s)
- Nunu Laura Timotheussen Lund
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark.
- Department of Neurology, Sjællands Universitetshospital Roskilde, Roskilde, Denmark.
| | - Anja Sofie Petersen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederlands (SEIN), Sleep-Wake Centre, Heemstede, The Netherlands
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Forensic Medicine, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Andrea Carmine Belin
- Centre for Cluster Headache, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tore Meisingset
- Norwegian Advisory Unit On Headaches, St. Olav University Hospital, Trondheim, Norway
- NorHEAD, Norwegian Headache Research Centre, NTNU, Trondheim, Norway
| | - Erling Tronvik
- Norwegian Advisory Unit On Headaches, St. Olav University Hospital, Trondheim, Norway
- NorHEAD, Norwegian Headache Research Centre, NTNU, Trondheim, Norway
| | - Anna Steinberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Charly Gaul
- Charly Gaul, Headache Center, Frankfurt, Germany
| | - Rigmor Højland Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Valdemar Hansens Vej 5, 2600, Glostrup, Denmark
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Ghosh A, Varghese L, Burish MJ, Szperka CL. Trigeminal Autonomic Cephalalgias and Neuralgias in Children and Adolescents: a Narrative Review. Curr Neurol Neurosci Rep 2023; 23:539-549. [PMID: 37572226 DOI: 10.1007/s11910-023-01288-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE OF REVIEW To summarize the available literature as well as the authors' experience on trigeminal autonomic cephalalgias (TACs) and cranial neuralgias in children and adolescents. RECENT FINDINGS While TACs and cranial neuralgias are rare in children, several recent case series have been published. TACs in children share most of the clinical features of TACs in adults. However, there are many reported cases with clinical features which overlap more than one diagnosis, suggesting that TACs may be less differentiated in youth. Indomethacin-responsive cases of cluster headache and SUNCT/SUNA have been reported in children, whereas in adults indomethacin is usually reserved for paroxysmal hemicrania and hemicrania continua. Neuralgias appear to be rare in children. Clinical features are often similar to adult cases, though clinicians should maintain a high index of suspicion for underlying causes.
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Affiliation(s)
- Ankita Ghosh
- Division of Child Neurology, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Leena Varghese
- Pediatric Headache Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark J Burish
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Christina L Szperka
- Pediatric Headache Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Lee MJ, Park JW, Chu MK, Moon HS, Chung PW, Chung JM, Sohn JH, Kim BK, Kim BS, Kim SK, Song TJ, Choi YJ, Park KY, Oh K, Ahn JY, Lee KS, Bae DW, Cho SJ. Treatment pattern and response for cluster headache in Korea: A prospective multicenter observation study. Cephalalgia 2023; 43:3331024231159627. [PMID: 36855967 DOI: 10.1177/03331024231159627] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Only limited data are available regarding the treatment status and response to cluster headache in an Asian population. Therefore, this study aimed to provide a real-world treatment pattern of cluster headache and the response rate of each treatment in an Asian population. METHODS Patients with cluster headache were recruited between September 2016 and January 2019 from 16 hospitals in Korea. At the baseline visit, we surveyed the patients about their previous experience of cluster headache treatment, and acute and/or preventive treatments were prescribed at the physician's discretion. Treatment response was prospectively evaluated using a structured case-report form at 2 ± 2 weeks after baseline visit and reassessed after three months. RESULTS Among 295 recruited patients, 262 experiencing active bouts were included. Only one-third of patients reported a previous experience of evidence-based treatment. At the baseline visit, oral triptans (73.4%), verapamil (68.3%), and systemic steroids (55.6%) were the three most common treatments prescribed by the investigators. Most treatments were given as combination. For acute treatment, oral triptans and oxygen were effective in 90.1% and 86.8% of the patients, respectively; for preventive treatment, evidence-based treatments, i.e. monotherapy or different combinations of verapamil, lithium, systemic steroids, and suboccipital steroid injection, helped 75.0% to 91.8% of patients. CONCLUSION Our data provide the first prospective analysis of treatment responses in an Asian population with cluster headache. The patients responded well to treatment despite the limited availability of treatment options, and this might be attributed at least in part by combination of medications. Most patients were previously undertreated, suggesting a need to raise awareness of cluster headache among primary physicians.
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Affiliation(s)
- Mi Ji Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Wook Park
- Department of Neurology, Uijeongbu St. Mary's Hospital, Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Heui-Soo Moon
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pil-Wook Chung
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Myun Chung
- Department of Neurology, Inje University College of Medicine, Seoul, Korea
| | - Jong-Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Byung-Kun Kim
- Department of Neurology, Eulji University School of Medicine, Seoul, Korea
| | - Byung-Su Kim
- Department of Neurology, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Soo-Kyoung Kim
- Department of Neurology and Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | | | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Kyungmi Oh
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
| | - Jin-Young Ahn
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Kwang-Soo Lee
- Department of Neurology, Seoul St. Mary's Hospital, Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dae Woong Bae
- Department of Neurology, The Catholic University of Korea, St Vincent's Hospital, Suwon, Republic of Korea
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
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12
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Gravdahl GB, Aakerøy L, Stovner LJ, Engstrøm M, Müller KI, Bjørk MH, Tronvik E. Continuous positive airway pressure in cluster headache: A randomized, placebo-controlled, triple-blind, crossover study. Cephalalgia 2023; 43:3331024221128273. [PMID: 36620891 DOI: 10.1177/03331024221128273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Oxygen inhalation aborts cluster headache attacks, and case reports show the effect of continuous positive airway pressure. The aim of this study was to investigate the prophylactic effect of continuous positive airway pressure in chronic cluster headache. METHODS This was a randomized placebo-controlled triple-blind crossover study using active and sham continuous positive airway pressure treatment for chronic cluster headache. Patients entered a one month's baseline period before randomly being assigned to two months' active continuous positive airway pressure treatment followed by a four weeks' washout period and two months' sham continuous positive airway pressure or vice versa. Primary outcome measure was number of cluster headache attacks/week. RESULTS Of the 30 included participants (12 males, median age 49.5 years, min-max 20-66 years), 25 completed both treatment/sham cycles (two discontinued, three lost to follow-up). The median number of cluster headache attacks per week was reduced from 8.25 (0.75-89.75) attacks to 6.25 (0-56.00) attacks for active continuous positive airway pressure and to 7.50 (0.50-43.75) attacks for sham continuous positive airway pressure, but there was no difference in active versus sham (p = 0.904). One patient had a serious adverse event during active treatment, none occurred during sham treatment. CONCLUSIONS Continuous positive airway pressure treatment did not reduce the number of cluster headache attacks compared to sham treatment in chronic cluster headache patients. TRIAL REGISTRATION CLINICALTRIALS.GOV NCT03397563.
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Affiliation(s)
- Gøril Bruvik Gravdahl
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Norwegian Advisory Unit on Headaches, St. Olav University Hospital, Trondheim, Norway.,NorHEAD, Norwegian Headache Research Centre, Norway
| | - Lars Aakerøy
- Department of Thoracic Medicine, St. Olav University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | - Lars Jacob Stovner
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Norwegian Advisory Unit on Headaches, St. Olav University Hospital, Trondheim, Norway.,NorHEAD, Norwegian Headache Research Centre, Norway
| | - Morten Engstrøm
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Department of Neurology and Clinical Neurophysiology, St. Olav University Hospital
| | - Kai Ivar Müller
- Department of Neurology and National Neuromuscular Centre, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Marte Helene Bjørk
- NorHEAD, Norwegian Headache Research Centre, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Erling Tronvik
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Norwegian Advisory Unit on Headaches, St. Olav University Hospital, Trondheim, Norway.,NorHEAD, Norwegian Headache Research Centre, Norway
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13
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Chwolka M, Goadsby PJ, Gantenbein AR. Comorbidity or combination - more evidence for cluster-migraine? Cephalalgia 2023; 43:3331024221133383. [PMID: 36694429 DOI: 10.1177/03331024221133383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND While migraine and cluster headache share some clinical features and therapies, they differ considerably in the frequency and duration of the headache, as well as the inter-attack, or inter-bout, pathophysiology. Neither is fully understood, with their shared pathways being of interest. FINDINGS Five patients for whom it was difficult to distinguish migraine from cluster headache are presented. They had aspects of their phenotypes, which could be attributed to both disorders. Each patient was thoroughly examined, excluding secondary causes of headache, and had been treated with a number of medicines. CONCLUSION A correct diagnosis is key to the appropriate treatment approach. Especially, if treatment is not successful for the suspected headache type, and enlargement of the diagnostic and therapeutic range, respectively, should be evaluated. Whether in such settings there is shared or different pathophysiology can only be speculated upon.
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Affiliation(s)
- Mateusz Chwolka
- Department of Medicine, University Hospital Zurich, Zürich, Switzerland
| | - Peter J Goadsby
- NIHR King's Clinical Research Facility, King's College London, London, United Kingdom.,Department of Neurology, University of California, Los Angeles, CA, USA
| | - Andreas R Gantenbein
- Neurorehabilitation and Pain, Zurzach Care, Bad Zurzach, Switzerland.,Department of Neurology, University Hospital Zurich, Zürich, Switzerland
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14
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Mo H, Kim BK, Moon HS, Cho SJ. Real-world experience with 240 mg of galcanezumab for the preventive treatment of cluster headache. J Headache Pain 2022; 23:132. [PMID: 36209047 PMCID: PMC9547445 DOI: 10.1186/s10194-022-01505-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Galcanezumab of 300 mg monthly is the FDA approved preventive medication for cluster headache (CH) during the cluster period. Compared to the 120 mg galcanezumab syringe for the treatment of migraines, the 100 mg syringe for CH has globally not been as widely available. The aim of our study was to investigate the preventive efficacy and tolerability of two 120 mg galcanezumab doses for episodic CH in clinical practices. Methods We evaluated patients with CH who received at least 1 dose of 240 mg (2 prefilled syringe of 120 mg) of galcanezumab in the 3 university hospitals from February 2020 to September 2021. In the patients with episodic CH, the efficacy and safety data of galcanezumab were analyzed regarding to the presence of the conventional preventive therapy at the timing of therapy of galcanezumab. The data of other subtypes of CH were separately described. Results In 47 patients with episodic CH, galcanezumab was started median 18 days after the onset of current bout (range 1–62 days) and 4 patients (10.8%) received second dose of galcanezumab. The median time to the first occurrence of 100% reduction from baseline in CH attacks per week after galcanezumab therapy was 17 days (25% to 75% quartile range: 5.0 ~ 29.5) in all patients with episodic CH, 15.5 days (3.8 ~ 22.1) in 36 patients with galcanezumab therapy add-on conventional preventive therapy, 21.0 days (12.0 ~ 31.5) in 11 patients started galcanezumab as initial preventive therapy. Among 33 patients with headache diary, the proportion of patients with 50% or more reduction in weekly CH attacks at week 3 from baseline were 78.8%. There was no significant difference in the proportion of patients with a reduction of at least 50% in weekly frequency of CH attacks at week 3 between 24 patients received galcanezumab therapy add-on conventional preventive therapy and 9 patient who received initial galcanezumab therapy. (83.3%, vs 66.7%, p = 0.36). There were no significant differences in proportion of “very much better or “much better” between 36 patients received galcanezumab therapy add-on conventional preventive therapy and 11 patient who received initial GT (86.1%, vs 63.6%, p = 0.18). Conclusion One 240 mg dose of galcanezumab with/without conventional therapy for the prevention of CH is considered effective and safe in clinical practices, as seen in the clinical trial of galcanezumab.
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Affiliation(s)
- Heejung Mo
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Keun Jae Bong-gil 7, Hwaseong, Gyeonggi-do, 18450, South Korea
| | - Byung-Kun Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea
| | - Heui-Soo Moon
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Keun Jae Bong-gil 7, Hwaseong, Gyeonggi-do, 18450, South Korea.
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15
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Peng KP, Jürgens T, Basedau H, Ortlieb L, May A. Sumatriptan prevents central sensitisation specifically in the trigeminal dermatome in humans. Eur J Pain 2022; 26:2152-2161. [PMID: 36001070 DOI: 10.1002/ejp.2027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 07/22/2022] [Accepted: 08/20/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The exact mechanism and site of action of triptans in aborting migraine attacks remain under debate. We hypothesized that the clinical efficacy of triptans lies in aborting central sensitization and focused on the question of why triptans are headache-specific, i.e. highly effective in migraine and cluster headache and ineffective in extracephalic pain. METHODS Forty healthy participants were enrolled in this double-blinded, randomized, placebo-controlled study. The effect of sumatriptan (n=20) vs placebo (n=20) was investigated in a cephalic (V1) vs an extracephalic dermatome (forearm) using a topical capsaicin sensitization model. Capsaicin-induced primary and secondary hyperalgesia were evaluated using quantitative sensory testing. RESULTS After capsaicin application, primary hyperalgesia developed in both sumatriptan and placebo groups in both dermatomes. However, sumatriptan exclusively prevented secondary hyperalgesia in the V1 dermatome but not on the forearm. Placebo exerted no effects on secondary hyperalgesia in both trigeminal and extracephalic dermatomes. Additionally, sumatriptan reduced the flare size exclusively in the V1 dermatome. CONCLUSIONS Our data suggest that sumatriptan reduces central sensitization (secondary hyperalgesia) without modulating peripheral sensitization (primary hyperalgesia) in a human pain model of capsaicin-induced sensitization. Moreover, despite a systemic administration of sumatriptan, the modulatory effects are trigeminal-specific, echoing the clinical effect of triptans in aborting headaches, but not extracephalic pain.
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Affiliation(s)
- Kuan-Po Peng
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Jürgens
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, KMG Medical Center, Güstrow, Germany
| | - Hauke Basedau
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Luise Ortlieb
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Schoenen J, Snoer AH, Brandt RB, Fronczek R, Wei DY, Chung CS, Diener HC, Dodick DW, Fontaine D, Goadsby PJ, Matharu MS, May A, McGinley JS, Tepper SJ, Jensen RH, Ferrari MD, Schoenen J, Jensen R, Ferrari MD, May A, Diener HC, Goadsby PJ, Matharu MS, Tepper SJ, Dodick DW, Chung CS, Fontaine D, McGinley JS, Snoer AH, Fronczek R, Brandt RW, Wei DY, Terwindt G, Tassorelli C, Diener HC, Ashina M, Goadsby PJ, Leroux E, Lipton RB, Pozo-Rosich P, Wang SJ, Christensen MD, Martini D, van den Hoek T. Guidelines of the International Headache Society for Controlled Clinical Trials in Cluster Headache. Cephalalgia 2022; 42:1450-1466. [DOI: 10.1177/03331024221120266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 1995, a committee of the International Headache Society developed and published the first edition of the Guidelines for Controlled Trials of Drugs in Cluster Headache. These have not been revised. With the emergence of new medications, neuromodulation devices and trial designs, an updated version of the International Headache Society Guidelines for Controlled Clinical Trials in Cluster Headache is warranted. Given the scarcity of evidence-based data for cluster headache therapies, the update is largely consensus-based, but takes into account lessons learned from recent trials and demands by patients. It is intended to apply to both drug and neuromodulation treatments, with specific proposals for the latter when needed. The primary objective is to propose a template for designing high quality, state-of-the-art, controlled clinical trials of acute and preventive treatments in episodic and chronic cluster headache. The recommendations should not be regarded as dogma and alternative solutions to particular methodological problems should be explored in the future and scientifically validated.
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Affiliation(s)
- Jean Schoenen
- CHU de Liège, Neurology, Headache Research Unit, Citadelle Hospital, Liège, Belgium
| | | | | | - Rolf Fronczek
- Leiden University Medical Center, Leiden, Netherlands
| | - Diana Y Wei
- King’s College London, Headache Group, London, UK
| | - Chin-Sang Chung
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Soeul, Republic of Korea
| | | | - David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | | | | | - Arne May
- Universitäts-Krankenhaus Eppendorf, Systems Neuroscience, Hamburg, Germany
| | - James S McGinley
- Vector Psychometric Group, Behaviorial Analytics, Chapel Hill, North Carolina, USA
| | - Stewart J Tepper
- Dartmouth-Hitchcock, Department of Neurology, Lebanon, New Hampshire, USA
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17
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Rusanen SS, De S, Schindler EAD, Artto VA, Storvik M. Self-Reported Efficacy of Treatments in Cluster Headache: a Systematic Review of Survey Studies. Curr Pain Headache Rep 2022; 26:623-637. [PMID: 35759175 PMCID: PMC9436841 DOI: 10.1007/s11916-022-01063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The use and efficacy of various substances in the treatment of CH have been studied in several retrospective surveys. The aim of the study is to systematically review published survey studies to evaluate the reported efficacies of both established and unconventional substances in abortive and prophylactic treatment of both episodic and chronic CH, specifically assessing the consistency of the results. RECENT FINDINGS No systematic review have been conducted of these studies previously. A systematic literature search with a set of search terms was conducted on PubMed. Retrospective surveys that quantified the self-reported efficacy of two or more CH treatments, published in English during 2000-2020, were included. Several key characteristics and results of the studies were extracted. A total of 994 articles were identified of which 9 were found to be eligible based on the selection criteria. In total, 5419 respondents were included. Oxygen and subcutaneous triptan injections were most reported as effective abortive treatments, while psilocybin and lysergic acid diethylamide were most commonly reported as effective prophylactic treatments. The reported efficacy of most substances was consistent across different studies, and there were marked differences in the reported efficacies of different substances. The reported order of efficacy is generally in agreement with clinical studies. The findings suggest that retrospective surveys can be used to obtain supporting information on the effects of various substances used in the treatment of CH and to form hypotheses about novel treatment methods. The consistently reported efficacy of psilocybin and LSD in prophylactic treatment indicates need for clinical studies.
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Affiliation(s)
| | - Suchetana De
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | - Ville Aleksi Artto
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Markus Storvik
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.
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18
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Chiang CC, Halker Singh RB. Acute Treatment of Headache (Focus on Migraine). Semin Neurol 2022; 42:494-502. [DOI: 10.1055/s-0042-1757926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractAcute treatments for migraine and cluster headache are necessary to abort attacks, relieve pain and associated symptoms, and restore an individual's ability to function. Acute headache treatments consist of a variety of medication and nonmedication options. In this article, we discuss the approach to acute treatment of migraine and cluster headache. We summarize the level of evidence to support each acute medication class according to recent systematic reviews and meta-analyses, as well as guideline recommendations from the American Headache Society, American Academy of Neurology, and European Federation of Neurological Society.
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19
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Mo H, Chung SJ, Rozen TD, Cho SJ. Oxygen Therapy in Cluster Headache, Migraine, and Other Headache Disorders. J Clin Neurol 2022; 18:271-279. [PMID: 35589316 PMCID: PMC9163947 DOI: 10.3988/jcn.2022.18.3.271] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 11/17/2022] Open
Abstract
Oxygen therapy (OT) can relieve head pain in certain primary headache disorders, including cluster headache (CH). The exact underlying mechanism is currently uncertain, but suggested mechanisms include inhibition of the trigeminoautonomic reflex, modulation of neurotransmitters, and cerebral vasoconstriction. OT is the standard for acute treatment of CH, but patients with CH often experience considerable difficulties accessing home OT due to problems with insurance coverage. Inhalation of 100% oxygen at 6–12 L/min for 15–30 min using a non-rebreather face mask is one of the most effective acute therapies for CH, but several trials have indicated the superiority of higher oxygen flow rates of up to 15 L/min and/or using a demand-valve oxygen mask that can produce very high flow rates. Two randomized controlled trials have demonstrated the efficacy of OT in migraine, but obtaining reliable evidence is considered difficult because of different inhalation protocols, varying outcome measures, and small samples. There are some reports on the efficacy of OT as an adjuvant therapy in hypnic headache, primary headache in the emergency department, and even postdural puncture headache. The goal of this review article is to expand the knowledge regarding the use of oxygen in the treatment of headache disorders.
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Affiliation(s)
- Heejung Mo
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Soo Jie Chung
- Department of Pulmonology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Todd D Rozen
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
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20
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[Galcanezumab for episodic and chronic cluster headache]. Schmerz 2022; 37:168-174. [PMID: 35476143 DOI: 10.1007/s00482-022-00648-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/14/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cluster headache (CH) is a highly debilitating headache disorder characterized by frequent attacks of excruciating unilateral pain accompanied by cranial autonomic symptoms. Calcitonin gene-related peptide (CGRP) is implicated in the pathophysiology of CH. OBJECTIVES Preventive efficacy and tolerability of the anti-CGRP antibody galcanezumab in patients with episodic (eCH) and chronic CH (cCH). Review of the study results and the challenges in developing drugs for the preventive treatment of CH. MATERIALS AND METHODS In two international multicenter phase III trials galcanezumab 300 mg given subcutaneously every 4 weeks was compared with placebo. The double-blind study period (8 weeks in eCH, 12 weeks in cCK) was preceded by a baseline period in both trials. The primary endpoint was the reduction in weekly attack frequency. RESULTS In the eCH trial, 106 patients were randomized to either galcanezumab (n = 49) or placebo (n = 57). The mean weekly attack frequency during the first 3 weeks decreased by 52% in the galcanezumab group compared with 27% in the placebo group (p = 0.036). In the cCH trial, 237 patients were randomized to galcanezumab (n = 117) or placebo (n = 120). The primary endpoint was not met in this study. The reduction in mean weekly attack rate was 5.4 with galcanezumab versus 4.6 with placebo (p = 0.334). Galcanezumab was well tolerated in both studies. CONCLUSIONS Galcanezumab had a significant effect in the prevention of eCH attacks but not in cCH. Possible reasons for this discrepancy are discussed.
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21
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Dodick DW, Goadsby PJ, Ashina M, Tassorelli C, Hundemer HP, Bardos JN, Wenzel Md R, Kemmer P, Conley R, Martinez JM, Oakes T. Challenges and complexities in designing cluster headache prevention clinical trials: A narrative review. Headache 2022; 62:453-472. [PMID: 35363381 PMCID: PMC9325511 DOI: 10.1111/head.14292] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 12/28/2022]
Abstract
Objective To provide a review of challenges in clinical trials for the preventive treatment of cluster headache (CH) and highlight considerations for future studies. Background Current guidelines for preventive treatment of CH are largely based on off‐label therapies supported by a limited number of small randomized controlled trials. Guidelines for clinical trial design for CH treatments from the International Headache Society were last issued in 1995. Methods/Results Randomized controlled clinical trials were identified in the European and/or United States clinical trial registries with a search term of “cluster headache,” and manually reviewed. Cumulatively, there were 27 unique placebo‐controlled prevention trials for episodic and/or chronic CH, of which 12 were either ongoing, not yet recruiting, or the status was unknown. Of the remaining 15 trials, 5 were terminated early and 7 of the 10 completed trials enrolled fewer patients than planned or did not report the planned sample size. A systematic search of PubMed was also utilized to identify published manuscripts reporting results from placebo‐controlled preventive trials of CH. This search yielded 16 publications, of which 7 were registered. Through critical review of trial data and published manuscripts, challenges and complexities encountered in clinical trials for the preventive treatment of CH were identified. For example, the excruciating pain associated with CH demands a suitably limited baseline duration, rapid treatment efficacy onset, and poses a specific issue regarding duration of investigational treatment period and length of exposure to placebo. In episodic CH, spontaneous remission as part of natural history, and the unpredictability and irregularity of cluster periods across patients present additional key challenges. Conclusions Optimal CH trial design should balance sound methodology to demonstrate efficacy of a potential treatment with patient needs and the natural history of the disease, including unique outcome measures and endpoint timings for chronic versus episodic CH.
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Affiliation(s)
- David W Dodick
- Department of Neurology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Peter J Goadsby
- National Institute for Health Research (NIHR) Wellcome Trust King's Clinical Research Facility, King's College London, London, UK.,Department of Neurology, University of California, Los Angeles, California, USA
| | - Messoud Ashina
- Department of Neurology, Danish Headache Center, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Cristina Tassorelli
- Headache Science Centre, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | | | | | | | - Phebe Kemmer
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Robert Conley
- Eli Lilly and Company, Indianapolis, Indiana, USA.,University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Tina Oakes
- Eli Lilly and Company, Indianapolis, Indiana, USA
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22
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Moond V, Hamilton K, Martinez R, Carrizo C, Burish M. Refractory Short-Lasting Unilateral Neuralgiform Headache Attacks With Conjunctival Injection and Tearing (SUNCT) Responding to Erenumab Adjuvant Therapy: A Case Report. Cureus 2022; 14:e24403. [PMID: 35619866 PMCID: PMC9126469 DOI: 10.7759/cureus.24403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/06/2022] Open
Abstract
Many patients with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) fail to respond to the first-line treatment of lamotrigine. Additionally, data for other treatments are limited in this rare headache disorder. SUNCT involves activation of the trigeminal nerve which uses the neuropeptide calcitonin gene-related peptide (CGRP); thus CGRP-targeted treatments may be beneficial in this disorder. We present a patient with SUNCT who failed to respond optimally to 10 medications and four surgical treatments. However, she had minimal attacks after erenumab 140 mg was added to carbamazepine 200 mg three times daily and pregabalin 75 mg twice daily. Decreasing any of these three medications worsened her attacks. Our case represents the second case report of a SUNCT patient responding to a CGRP monoclonal antibody, suggesting this treatment may be a consideration in refractory SUNCT.
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Affiliation(s)
- Vishali Moond
- Internal Medicine, University College of Medical Sciences, Delhi, IND
| | - Katherine Hamilton
- Department of Neurology, Georgetown University Medical Center, Washington DC, USA
| | - Rebecca Martinez
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, USA
| | - Claudia Carrizo
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, USA
| | - Mark Burish
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, USA
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Abstract
Cluster headache, a primary headache disorder, consists of short (15-180 minutes), frequent (up to eight a day), unilateral attacks of facial pain with associated ipsilateral autonomic features and restlessness. The attacks are suspected to be one of the most painful human experiences, and the disorder is associated with a high rate of suicidal ideation. Proper diagnosis is key, as some of the most effective treatments, such as high flow oxygen gas, are rarely used in other headache disorders. Yet diagnostic delay is typically years for this disorder, as it is often confused with migraine and trigeminal neuralgia, and secondary causes may be overlooked. This review covers the clinical, pathophysiologic, and therapeutic features of cluster headache. Recent updates in diagnosis include the redefinition of chronic cluster headache (remission periods lasting less than three months instead of the previous one month), and recent advances in management include new treatments for episodic cluster headache (galcanezumab and non-invasive vagus nerve stimulation).
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Affiliation(s)
- Emmanuelle A D Schindler
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Veterans Health Administration Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, CT
| | - Mark J Burish
- Department of Neurosurgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
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Sico JJ, Macedo F, Lewis J, Spevak C, Vogsland R, Ford A, Skop K, Sall J. The Primary Care Management of Headache: Synopsis of the 2020 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Mil Med 2022; 187:e1091-e1102. [PMID: 35022782 DOI: 10.1093/milmed/usab490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/20/2021] [Accepted: 01/09/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION In June of 2020, the U.S. DVA and DoD approved a new joint clinical practice guideline for assessing and managing patients with headache. This guideline provides a framework to evaluate, treat, and longitudinally manage the individual needs and preferences of patients with headache. METHODS In October of 2018, the DVA/DoD Evidence-Based Practice Work Group convened a guideline development panel that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. RESULTS The guideline panel developed key questions, systematically searched and evaluated the literature, created a 1-page algorithm, and advanced 42 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. CONCLUSION This synopsis summarizes the key features of the guideline in three areas: prevention, assessing and treating medication overuse headache, and nonpharmacologic and pharmacologic management of headache.
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Affiliation(s)
- Jason J Sico
- Headache Centers of Excellence (HCoE) Program, National Programs Center, Orange, CT 06477, USA.,HCoE Research and Evaluation Center, Veterans Health Administration.,Department of Neurology (Headache Medicine and Vascular Neurology) and Internal Medicine (General Medicine), Yale School of Medicine, New Haven, CT 06520, USA.,VA Connecticut Healthcare System Department of Neurology, National Programs Center, Orange, CT 06477, USA
| | - Franz Macedo
- Minneapolis VA Health Care System, Minneapolis, MN 55417, USA
| | - Jeffrey Lewis
- Wright-Patterson Air Force Base Mental Health Clinic, Wright-Patterson AFB, OH 45433, USA
| | - Christopher Spevak
- Physical Medicine and Rehabilitation Service, James A. Haley Veterans' Hospital, Tampa, FL 33612, USA.,Minneapolis VA Health Care System, Minneapolis, MN 55417, USA
| | | | - Aven Ford
- USAFSAM/FECN, Wright-Patterson AFB, OH 45433, USA
| | - Karen Skop
- Physical Medicine and Rehabilitation Service, James A. Haley Veterans' Hospital, Tampa, FL 33612, USA
| | - James Sall
- Quality and Patient Safety, Office of Evidence Based Practice, U.S. Department of Veterans Affairs, New Braunfels, TX 78132, USA.,Department of Clinical Anesthesia, Georgetown University School of Medicine.,Program Director Pain Fellowship, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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Pohl H. History of cluster headache. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221128183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To summarise the history of cluster headache evolving concepts and growing insights. Background: Excruciating pain, activation of the parasympathetic nervous system, and circadian rhythmicity characterise cluster headache attacks. Results: We find the oldest descriptions of patients suffering from the disorder in case reports of the 17th and 18th centuries. Only in the 19th and early 20th centuries did physicians start hypothesizing its cause. Initially, many researchers suspected the origin of the pain in peripheral nerves or blood vessels. However, eventually, they understood that the cause of the disease lies in the brain. In 1998, Positron emission tomography studies revealed increased activity of the posterior hypothalamus, whose role remains incompletely understood. Only recently have researchers realised that being diseased implies more than dysfunction. Recent studies analysed the consequences of cluster headache for each patient. Many struggle to deal with the disorder even in the absence of pain. Conclusion: Physicians have been aware of this type of pain for at least 300 years. Only when researchers studied pathological anatomy and physiology did knowledge accrue. A more comprehensive picture of the disease severity emerged when they also considered its consequences.
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Affiliation(s)
- Heiko Pohl
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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Bolte KN, Assaf M, Zach T, Peche S. Two Children with Early-Onset Strokes and Intractable Epilepsy, Both with CACNA1A Mutations. Child Neurol Open 2022; 9:2329048X221094977. [PMID: 35497372 PMCID: PMC9052233 DOI: 10.1177/2329048x221094977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/12/2022] [Accepted: 03/24/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Mutations in the CACNA1A gene have been associated phenotypically with Familial Hemiplegic Migraine Type 1, Episodic Ataxia Type 2, Idiopathic Generalized Epilepsy, and Developmental and Epileptic Encephalopathy 42. Only six cases have linked ischemic strokes to mutations in the CACNA1A gene. Summary of Cases: We describe two unrelated patients who were found to have different mutations of the CACNA1A gene, one being a novel mutation, as shown by whole exome sequencing. One presented with seizures at birth and the other with seizures at 17 months old, both eventually exhibiting intractable epilepsy, ischemic stroke, and developmental delays. Results: Whole exome sequencing demonstrated de novo pathogenic mutations in the CACNA1A gene, which both caused similar phenotypes in unrelated patients. Conclusion: Pediatric patients who present with ischemic stroke and a history of seizures should be evaluated for CACNA1A mutations, as prompt recognition can help providers facilitate appropriate medical management.
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Affiliation(s)
- Kristen N Bolte
- Midwestern University Arizona College of Osteopathic Medicine, Glendale, AZ, USA
| | - Melissa Assaf
- Section of Child Neurology, Department of Pediatrics, Banner Thunderbird Medical Center, Glendale, AZ, USA
| | - Tamara Zach
- Section of Child Neurology, Department of Pediatrics, Banner Thunderbird Medical Center, Glendale, AZ, USA
| | - Shubhangi Peche
- Section of Child Neurology, Department of Pediatrics, Banner Thunderbird Medical Center, Glendale, AZ, USA
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Pérez-Pereda S, Madera J, González-Quintanilla V, Drake-Pérez M, Marzal Espí CN, Serrano Munuera C, García SC, Aguilella Linares C, Fernández Recio M, Velamazán Delgado G, Pascual J. Is conventional brain MRI useful for the diagnosis of cluster headache in patients who meet ICHD-3 criteria? Experience in three hospitals in Spain. J Neurol Sci 2021; 434:120122. [PMID: 34979370 DOI: 10.1016/j.jns.2021.120122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/24/2021] [Accepted: 12/21/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the frequency of symptomatic structural lesions and the diagnostic yield of conventional brain MRI in cluster headache (CH). BACKGROUND In contrast to migraine, brain MRI is recommended in patients with CH to exclude potential mimics. The prevalence of symptomatic CH is not known. METHODS We retrospectively analysed in detail the brain MRIs of patients diagnosed as CH in 3 Neurology Services in Spain and reviewed their clinical history. Clinical diagnoses were reassessed based on the ICHD-3 criteria. RESULTS We included 130 patients: 113 (86.9%) were male; mean age at diagnosis being 41.4 years (range 7-82). Forty-nine (37.7%) showed some abnormal MRI finding. Only in two cases potential symptomatic lesions were found: one trigeminal schwannoma and one craneopharyngioma, but both presented atypical features (facial hypoesthesia on examination and episodes of prolonged duration that had progressed to continuous refractory pain without specific pattern, respectively) and therefore did not fulfil the ICHD-3 CH criteria. The remaining abnormal MRI findings were: white matter lesions (24 patients; 18.4%), sinus inflammatory changes (13; 10.0%), small arachnoid cysts (5; 3.8%), empty sella turca (3; 2.3%), and other unspecific findings (8; 6.2%). All of them were not symptomatic based on neuroimaging characteristics, clinical course and response to treatment. CONCLUSIONS Brain MRI in patients who meet ICHD-3 CH criteria, with no atypical clinical features, does not show any clinically-relevant findings, suggesting that these criteria are highly predictive of its primary origin and that systematic MRI is not useful for the diagnosis of typical CH.
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Affiliation(s)
- Sara Pérez-Pereda
- Service of Neurology, University Hospital Marqués de Valdecilla, University of Cantabria and IDIVAL, Santander, Spain
| | - Jorge Madera
- Service of Neurology, University Hospital Marqués de Valdecilla, University of Cantabria and IDIVAL, Santander, Spain
| | - Vicente González-Quintanilla
- Service of Neurology, University Hospital Marqués de Valdecilla, University of Cantabria and IDIVAL, Santander, Spain
| | - Marta Drake-Pérez
- Service of Radiology, University Hospital Marqués de Valdecilla and IDIVAL, Santander, Spain
| | | | | | - Silvia Cusó García
- Service of Neurology, Fundació Hospital Sant Joan de Déu, Martorell, Barcelona, Spain
| | | | | | | | - Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, University of Cantabria and IDIVAL, Santander, Spain.
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Serousova OV, Karpova MI. [Trigeminal autonomic cephalgias: features of diagnosis and treatment]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:105-112. [PMID: 34874664 DOI: 10.17116/jnevro2021121101105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trigeminal autonomic cephalgias is a group of primary headaches, including cluster headache, paroxysmal hemicrania and hemicrania continua, as well as two forms of short- lasting unilateral neuralgiform headache attacks, the complexity of diagnosis of which is determined by the low prevalence and some similarity of clinical manifestations both among themselves and with other diseases in particular with migraine and trigeminal neuralgia. Despite the rather short duration of headache attacks, the intensity of the pain syndrome reaches a severe and very severe degree, and the high frequency of paroxysms per day significantly complicates abortion treatment and leads to a pronounced professional and social maladjustment. At the same time, the possibility of using effective specific prophylactic therapy determines the importance of accurate diagnosis and, therefore, the knowledge of neurologists on this issue.
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Affiliation(s)
- O V Serousova
- South Ural State Medical University, Chelyabinsk, Russia
| | - M I Karpova
- South Ural State Medical University, Chelyabinsk, Russia
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Láinez MJA, Schoenen J, Stroud C, Bardos J, Bangs M, Kemmer P, Wenzel R, Kuruppu DK, Martinez JM, Oakes TM. Tolerability and safety of galcanezumab in patients with chronic cluster headache with up to 15 months of galcanezumab treatment. Headache 2021; 62:65-77. [PMID: 34806783 PMCID: PMC9299588 DOI: 10.1111/head.14234] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/23/2021] [Accepted: 09/20/2021] [Indexed: 01/03/2023]
Abstract
Objective The objective of the study was to assess the tolerability and safety of galcanezumab in patients with chronic cluster headache (CH) with up to 15 months of treatment. Background Chronic CH is a highly debilitating disease with a substantial and unmet medical need. Methods Patients were randomized to receive placebo or galcanezumab (300 mg) monthly for 12 weeks, followed by an optional 52‐week open‐label extension and 16‐week posttreatment follow‐up (washout). This is a secondary analysis and long‐term follow‐up of a previously conducted clinical trial. The safety analysis included patients who received galcanezumab at any time during the study. Outcomes included adverse events (AEs), discontinuations, laboratory values, vital signs, electrocardiograms (ECGs), and suicidality ratings. Results A total of 233 patients received at least one galcanezumab dose. The mean exposure was 341 days. Galcanezumab‐treated patients were mostly male (n = 169/233; 72.5%) with a mean age of 44.9 (±10.9) years. Treatment‐emergent adverse events (TEAEs) were reported by 185 patients (n = 185/233; 79.4%), 23 patients (n = 23/233; 9.9%) reported serious adverse events (SAEs), and 18 patients (n = 18/233; 7.7%) discontinued due to AEs. The SAE CH was reported by three patients. The most common TEAEs (>10%) were nasopharyngitis (n = 41/233; 17.6%) and injection site pain (n = 33/233; 14.2%). 27.5% of patients (n = 64/233) had TEAEs related to injection sites. Likely hypersensitivity events, including injection site rash, injection site urticaria, and injection site hypersensitivity were reported (n = 14/233; 6.0%). There were past histories of suicidal ideation (n = 55/237; 23.2%) and suicidal behavior (n = 9/236; 3.8%). During the study, 15 patients (n = 15/230; 6.5%), seven with previous history, reported suicidal ideation. One patient had a nonfatal suicide attempt during the open‐label extension and an aborted attempt during the washout. There were no new safety findings compared with the placebo‐controlled treatment period in laboratory values, vital signs, or ECGs. Conclusions Galcanezumab 300 mg monthly had a favorable tolerability and safety profile in patients with chronic CH with up to 15 months of treatment.
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Affiliation(s)
- Miguel J A Láinez
- Hospital Clinico Universitario, Universidad Católica de Valencia, Valencia, Spain
| | - Jean Schoenen
- Department of Neurology, Headache Research Unit, Citadelle Hospital, Liège University, Liège, Belgium
| | - Chad Stroud
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | - Mark Bangs
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Phebe Kemmer
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | | | - Tina M Oakes
- Eli Lilly and Company, Indianapolis, Indiana, USA
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30
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Tuncer Issı Z, Akbulut N, Öztürk V. Cluster headache: a single tertiary center study. Neurol Res 2021; 44:342-352. [PMID: 34781845 DOI: 10.1080/01616412.2021.1992101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECT The characteristics of cluster headache (CH) patients in many countries and the diagnostic and therapeutic approach have been described in several publications, but so far no clinical data have been published from Turkey. MATERIAL METHODS This is a cross-sectional retrospective study that includes all patients who were diagnosed with CH and referred to our headache clinic, Dokuz Eylül University Faculty of Medicine, Neurology Department from 1991 to January 2018. RESULTS We included 114 patients (24 females and 90 males) in our study. The mean age at onset was 31.68 ± 12.72 (range 13-68). Eighty-six (78.18%) patients had episodic cluster headache (ECH) and 24 (21.82%) patients had chronic cluster headache (CCH). The age at onset was significantly higher in the patients with CCH than with ECH (p = 0.002). The most common location was orbitotemporal for both genders. The most common accompanying symptoms were lacrimation (80.73%). The male:female ratio in all patients was 3:7, 3.8:1 in those with CCH and 4:1 in those with ECH. Eighty-nine (87.25%) patients had prophylactic treatment and 60 of them received verapamil. CONCLUSION In our study, some clinical features of our patients were similar to those of Europe and America or the Asian countries and some of them not. There are regional differences in cluster headache patients. With more awareness of cluster headache and research from many countries, clinical differences can be revealed more objectively in the future.
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Affiliation(s)
- Zeynep Tuncer Issı
- Department of Pain Management, Sakarya Research and Training Hospital, Sakarya, Turkey
| | - Nurcan Akbulut
- Department of Neurology, Bayburt State Hospital, Bayburt, Turkey
| | - Vesile Öztürk
- Faculty of Medicine Hospital, Department of Neurology, Dokuz Eylül University, Izmir, Turkey
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31
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Abstract
Cluster headache is a primary headache form occurring in paroxysmal excruciatingly severe unilateral head pain attacks usually grouped in periods lasting 1-2months, the cluster periods. A genetic component is suggested by the familial occurrence of the disease but a genetic linkage is yet to be identified. Contemporary activation of trigeminal and cranial parasympathetic systems-the so-called trigemino-parasympathetic reflex-during the headache attacks seem to cause the pain and accompanying oculo-facial autonomic phenomena respectively. At peripheral level, the increased calcitonin gene related peptide (CGRP) plasma levels suggests trigeminal system activation during cluster headache attacks. The temporal pattern of the disease both in terms of circadian rhythmicity and seasonal recurrence has suggested involvement of the hypothalamic biological clock in the pathophysiology of cluster headache. The posterior hypothalamus was investigate as the cluster generator leading to activation of the trigemino-parasympathetic reflex, but the accumulated experience after 20 years of hypothalamic electrical stimulation to treat the condition indicate that this brain region rather acts as pain modulator. Efficacy of monoclonal antibodies to treat episodic cluster headache points to a key role of CGRP in the pathophysiology of the condition.
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Andrews JS, Kudrow D, Rettiganti M, Oakes T, Bardos JN, Wenzel R, Kuruppu DK, Gaul C, Martinez JM. Impact of Galcanezumab on Total Pain Burden: A Post Hoc Analysis of a Phase 3, Randomized, Double-Blind, Placebo-Controlled Study in Patients with Episodic Cluster Headache. J Pain Res 2021; 14:2059-2070. [PMID: 34267550 PMCID: PMC8275210 DOI: 10.2147/jpr.s305066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 06/17/2021] [Indexed: 01/03/2023] Open
Abstract
Purpose In a phase 3 study, galcanezumab significantly reduced the frequency of episodic cluster headache attacks across weeks 1–3 (primary endpoint) compared with placebo. However, multiple pain dimensions may contribute to the total burden of episodic cluster headache pain. This post hoc analysis assessed the impact of galcanezumab on the total pain burden of episodic cluster headache using a composite measure. Patients and Methods Patients with episodic cluster headache were randomized 1:1 to galcanezumab 300 mg or placebo once monthly for 8 weeks. Mean weekly total pain burden was calculated (daily cluster headache attack frequency × average duration × average pain severity summed over 7 days) using data collected in an electronic patient-reported outcomes diary. Change from baseline in weekly total pain burden across weeks 1–3 was compared between galcanezumab and placebo. To explore construct validity, mean weekly total pain burden scores were stratified by Patient Global Impression of Improvement (PGI-I) responses at the week 4 clinic visit. Results The reduction from baseline in mean weekly total pain burden was significantly greater with galcanezumab (N=49) than with placebo (N=57): the least squares mean difference was −11.18 severity-weighted hours (p=0.035). Median weekly total pain burden decreased as PGI-I ratings improved, from 33.6 to 5.0 severity-weighted hours for patients who felt “very much worse” and “very much better,” respectively. Conclusion Galcanezumab significantly reduced mean weekly total pain burden compared with placebo in patients with episodic cluster headache. The composite pain measure demonstrated construct validity. Total pain burden may provide a holistic measure of the pain of episodic cluster headache. Clinical Trials ClinicalTrials.gov, NCT02397473.
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Affiliation(s)
| | - David Kudrow
- California Medical Clinic for Headache, Santa Monica, CA, USA
| | | | - Tina Oakes
- Eli Lilly and Company, Indianapolis, IN, USA
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Abstract
Background Key structures for the pathophysiology of primary headache disorders such as migraine, cluster headache, and other trigeminal autonomic cephalalgias were identified by imaging in the past years. Objective Available data on functional imaging in primary headache disorders are summarized in this review. Material and Methods We performed a MEDLINE search on December 27th, 2020 using the search terms "primary headache" AND "imaging" that returned 453 results in English, out of which 137 were labeled reviews. All articles were evaluated for content and relevance for this narrative review. Results The structure depicted most consistently using functional imaging in different states of primary headaches (without and with pain) was the posterior hypothalamus. Whole-brain imaging techniques such as resting-state functional resonance imaging showed a wide-ranging association of cortical and subcortical areas with human nociceptive processing in the pathophysiological mechanisms underlying the different TACs. Similarities of distinct groups of primary headache disorders, as well as their differences in brain activation across these disorders, were highlighted. Conclusion The importance of neuroimaging research from clinical practice point of view remains the reliable and objective distinction of each individual pain syndrome from one another. This will help to make the correct clinical diagnosis and pave the way for better and effective treatment in the future. More research will be necessary to fulfill this unmet need.
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Affiliation(s)
- Steffen Naegel
- Department of Neurology, Martin Luther University Halle- Wittenberg and University Hospital Halle, Halle (Saale), Germany
| | - Mark Obermann
- Department of Neurology, Klinikum Weser-Egge, Höxter, Germany
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34
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Piccinni C, Cevoli S, Ronconi G, Dondi L, Calabria S, Pedrini A, Maggioni AP, Esposito I, Addesi A, Favoni V, Pierangeli G, Cortelli P, Martini N. Insights into real-world treatment of cluster headache through a large Italian database: prevalence, prescription patterns, and costs. Expert Rev Clin Pharmacol 2021; 14:1165-1171. [PMID: 34030566 DOI: 10.1080/17512433.2021.1934448] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: This study aimed at estimating the treated cluster headache (CH) prevalence and describing prescription patterns and direct costs paid by the Italian National-Health-System.Methods: Through the ReS database (healthcare administrative data collection of a large sample of the Italian population), adults in treatment for CH (acute therapy with sumatriptan/subcutaneous or oxygen, associated with preventive therapy with verapamil or lithium) were selected. A cross-sectional analysis described the prevalence of CH-treated subjects repeated annually in 2013-2017. A longitudinal analysis of patients selected in 2013-2015 and followed for 2 years provided the prescription patterns.Results: The annual prevalence of CH-treated patients increased from 6.4×100,000 adults in 2013 to 6.7 in 2017. In 2013-2015, 570 patients (80.7% M; mean age 46) treated for CH were found. In 50.4%, the identifying CH treatment was sumatriptan/subcutaneous+verapamil. During follow-up, >1/3 changed the preventive drug and interruption was the most frequent modification, although acute treatments were still prescribed. The mean annual cost/patient ranged from €2,956 to €2,267; pharmaceuticals expenditure represented the 56.4% and 57.3%, respectively.Conclusions: This study showed an important unmet need among CH patients, carrying a high economic burden that should be considered in the evaluation of the impact of incoming therapies (e.g. Calcitonin-Gene-Related-Peptide antibodies).
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Affiliation(s)
- Carlo Piccinni
- Fondazione ReS (Ricerca E Salute) - Research and Health Foundation, Casalecchio di Reno (Bologna), Bologna, Italy
| | - Sabina Cevoli
- IRCCS, Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Giulia Ronconi
- Fondazione ReS (Ricerca E Salute) - Research and Health Foundation, Casalecchio di Reno (Bologna), Bologna, Italy
| | - Letizia Dondi
- Fondazione ReS (Ricerca E Salute) - Research and Health Foundation, Casalecchio di Reno (Bologna), Bologna, Italy
| | - Silvia Calabria
- Fondazione ReS (Ricerca E Salute) - Research and Health Foundation, Casalecchio di Reno (Bologna), Bologna, Italy
| | - Antonella Pedrini
- Fondazione ReS (Ricerca E Salute) - Research and Health Foundation, Casalecchio di Reno (Bologna), Bologna, Italy
| | - Aldo P Maggioni
- Fondazione ReS (Ricerca E Salute) - Research and Health Foundation, Casalecchio di Reno (Bologna), Bologna, Italy
| | | | | | - Valentina Favoni
- IRCCS, Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Giulia Pierangeli
- IRCCS, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Pietro Cortelli
- IRCCS, Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Nello Martini
- Fondazione ReS (Ricerca E Salute) - Research and Health Foundation, Casalecchio di Reno (Bologna), Bologna, Italy
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35
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Bjørk MH, Kristoffersen ES, Tronvik E, Egeland Nordeng HM. Management of cluster headache and other trigeminal autonomic cephalalgias in pregnancy and breastfeeding. Eur J Neurol 2021; 28:2443-2455. [PMID: 33852763 DOI: 10.1111/ene.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/07/2021] [Indexed: 11/26/2022]
Abstract
Many clinicians lack experience in managing trigeminal autonomic cephalalgias (TACs) in pregnancy and lactation. In addition to cluster headache, TACs include hemicrania continua, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/autonomic symptoms (SUNCT/SUNA). Treating these rare, severe headache conditions often requires off-label drugs that have uncertain teratogenic potential. In the last few years, several new treatment options and safety documentation have emerged, but clinical guidelines are lacking. This narrative review aimed to provide an updated clinical guide and good clinical practice recommendations for the management of these debilitating headache disorders in pregnancy and lactation.
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Affiliation(s)
- Marte-Helene Bjørk
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Espen Saxhaug Kristoffersen
- Department of General Practice, HELSAM, University of Oslo, Oslo, Norway.,Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Erling Tronvik
- Department of Neurology, St. Olav's University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hedvig Marie Egeland Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway.,Department of Child Health and Development, National Institute of Public Health, Oslo, Norway
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36
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Mavridis T, Breza M, Deligianni C, Mitsikostas DD. Current advances in the management of cluster headaches. Expert Opin Pharmacother 2021; 22:1931-1943. [PMID: 33989098 DOI: 10.1080/14656566.2021.1924148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Cluster headache (CH) is probably the most severe idiopathic pain condition, yet its current medical management remains poor.Areas covered: Only repurpose medicines are currently in use for the prevention of CH, partially because the pathophysiology of the condition is still elusive. In this article we performed a systematic review to evaluate the evidence for efficacy of the currently available or emerging treatments for CH.Expert opinion: We found several ongoing randomized clinical trials testing prophylactic treatments for CH and only few for the standard ones. Recent data from randomized trials with monoclonal antibodies targeting the calcitonin gene related peptide pathway (anti-CGRP mAbs) are controversial, although its role in the pathogenesis of the condition is well documented. This inconsistency may depict inadequacies in clinical trial designing. Anti-CGRP mAbs and antagonists of pituitary adenylate cyclase-activating polypeptide (PACAP) along with neuromodulation techniques, are curing the necessary valuable evidence that could illuminate the therapeutical future for cluster headache. Orexin pathway is another attractive target for CH treatment. To improve the evidence for efficacy, we further propose that the design of the clinical trials for CH needs to be radically reviewed to allow more patients to participate.
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Affiliation(s)
- Theodoros Mavridis
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianthi Breza
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Dimos D Mitsikostas
- 1 Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Schytz HW, Amin FM, Jensen RH, Carlsen L, Maarbjerg S, Lund N, Aegidius K, Thomsen LL, Bach FW, Beier D, Johansen H, Hansen JM, Kasch H, Munksgaard SB, Poulsen L, Sørensen PS, Schmidt-Hansen PT, Cvetkovic VV, Ashina M, Bendtsen L. Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 3rd edition, 2020. J Headache Pain 2021; 22:22. [PMID: 33832438 PMCID: PMC8034101 DOI: 10.1186/s10194-021-01228-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/12/2021] [Indexed: 12/19/2022] Open
Abstract
Headache and facial pain are among the most common, disabling and costly diseases in Europe, which demands for high quality health care on all levels within the health system. The role of the Danish Headache Society is to educate and advocate for the needs of patients with headache and facial pain. Therefore, the Danish Headache Society has launched a third version of the guideline for the diagnosis, organization and treatment of the most common types of headaches and facial pain in Denmark. The second edition was published in Danish in 2010 and has been a great success, but as new knowledge and treatments have emerged it was timely to revise the guideline. The recommendations for the primary headaches and facial pain are largely in accordance with the European guidelines produced by the European Academy of Neurology. The guideline should be used a practical tool for use in daily clinical practice for primary care physicians, neurologists with a common interest in headache, as well as other health-care professionals treating headache patients. The guideline first describes how to examine and diagnose the headache patient and how headache treatment is organized in Denmark. This description is followed by sections on the characteristics, diagnosis and treatment of each of the most common primary and secondary headache disorders and trigeminal neuralgia. The guideline includes many tables to facilitate a quick overview. Finally, the particular challenges regarding migraine and female hormones as well as headache in children are addressed.
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Affiliation(s)
- Henrik W Schytz
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark.
| | - Faisal M Amin
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Louise Carlsen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Stine Maarbjerg
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Nunu Lund
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Karen Aegidius
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Lise L Thomsen
- Specialized Pediatric Clinic, Jægersborgvej 66B, 2. Sal, 2800, Kgs. Lyngby, Denmark
| | - Flemming W Bach
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Dagmar Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Hanne Johansen
- The Migraine and Headache Association (https://www.hovedpineforeningen.dk), Toftehøj 90, 6470 Sydals, Denmark
| | - Jakob M Hansen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark.,National Headache Knowledge Center, Danish Headache Center, Rigshospitalet-Glostrup, Valdemar Hansen Vej 5, Glostrup, 2600, Denmark
| | - Helge Kasch
- Department of Neurology, Spinal Cord Injury Centre of Western Denmark, Viborg Hospital, Viborg, Denmark
| | - Signe B Munksgaard
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Lars Poulsen
- General Practice, Clinic Laegehuset Nr. Broby, Saksenballe 5, 5672, Broby, Denmark
| | | | | | - Vlasta V Cvetkovic
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
| | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, 2600, Glostrup, Denmark
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Burish MJ, Han C, Mawatari K, Wirianto M, Kim E, Ono K, Parakramaweera R, Chen Z, Yoo SH. The first-line cluster headache medication verapamil alters the circadian period and elicits sex-specific sleep changes in mice. Chronobiol Int 2021; 38:839-850. [PMID: 33829951 DOI: 10.1080/07420528.2021.1892127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Verapamil is the first-line preventive medication for cluster headache, an excruciating disorder with strong circadian features. Whereas second- and third-line preventives include known circadian modulators, such as melatonin, corticosteroids, and lithium, the circadian effects of verapamil are poorly understood. Here, we characterize the circadian features of verapamil using both in vitro and in vivo models. In Per2::LucSV reporter fibroblasts, treatment with verapamil (0.03-10 µM) showed a dose-dependent period shortening of the reporter rhythm which reached a nadir at 1 µM, and altered core clock gene expression at 10 µM. Mouse wheel-running activity with verapamil (1 mg/mL added to the drinking water) also resulted in significant period shortening and activity reduction in both male and female free-running wild-type C57BL6/J mice. The temporal patterns of activity reduction, however, differ between the two sexes. Importantly, piezo sleep recording revealed sexual dimorphism in the effects of verapamil on sleep timing and bout duration, with more pronounced adverse effects in female mice. We also found altered circadian clock gene expression in the cerebellum, hypothalamus, and trigeminal ganglion of verapamil-treated mice. Verapamil did not affect reporter rhythms in ex vivo suprachiasmatic nucleus (SCN) slices from Per2:Luc reporter mice, perhaps due to the exceptionally tight coupling in the SCN. Thus, verapamil affects both peripheral (trigeminal ganglion) and central (hypothalamus and cerebellum) nervous system structures involved in cluster headache pathophysiology, possibly with network effects instead of isolated SCN effects. These studies suggest that verapamil is a circadian modulator in laboratory models at both molecular and behavioral levels, and sex is an important biological variable for cluster headache medications. These observations highlight the circadian system as a potential convergent target for cluster headache medications with different primary mechanisms of action.
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Affiliation(s)
- Mark J Burish
- Department of Neurosurgery and Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
| | - Chorong Han
- Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
| | - Kazuaki Mawatari
- Department of Preventive Environment and Nutrition, Institute of Biomedical Sciences, Tokushima University Graduate School, Japan
| | - Marvin Wirianto
- Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
| | - Eunju Kim
- Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
| | - Kaori Ono
- Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
| | - Randika Parakramaweera
- Department of Neurosurgery and Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
| | - Zheng Chen
- Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
| | - Seung-Hee Yoo
- Biochemistry and Molecular Biology, The University of Texas Health Science Center at Houston, Houston, USA
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Vandevelde A, Benbrika S, Madigand J, Dollfus S. Common mechanisms involved in manic switch and pain relief induced by lamotrigine: A case report and a literature review. L'ENCEPHALE 2021; 47:235-237. [PMID: 33648755 DOI: 10.1016/j.encep.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 11/15/2022]
Affiliation(s)
- A Vandevelde
- Service de psychiatrie, centre Esquirol, CHU de Caen, 14000 Caen, France; UNICAEN, ISTS EA 7466, GIP Cyceron, Normandie Université, boulevard Henri-Becquerel, BP5229, 14074 Caen cedex, France; UNICAEN, UFR de médecine (Medical School), Normandie Université, 14000 Caen, France
| | - S Benbrika
- Service de psychiatrie, centre Esquirol, CHU de Caen, 14000 Caen, France
| | - J Madigand
- CHU de Caen, Service de psychiatrie de l'enfant et de l'adolescent, 14000 Caen, France; Inserm, U1077, neuropsychologie et imagerie de la mémoire humaine, UNICAEN, Normandie Université, 14000 Caen, France
| | - S Dollfus
- Service de psychiatrie, centre Esquirol, CHU de Caen, 14000 Caen, France; UNICAEN, ISTS EA 7466, GIP Cyceron, Normandie Université, boulevard Henri-Becquerel, BP5229, 14074 Caen cedex, France; UNICAEN, UFR de médecine (Medical School), Normandie Université, 14000 Caen, France.
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Shah R, Assis F, Narasimhan B, Khachadourian V, Zhou S, Tandri H, Tariq N. Trans-nasal high-flow dehumidified air in acute migraine headaches: A randomized controlled trial. Cephalalgia 2021; 41:968-978. [PMID: 33631965 DOI: 10.1177/0333102421997766] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intranasal high flow of dehumidified (dry) air results in evaporative cooling of nasal passages. In this randomized clinical trial, we investigated the effect of dry gas induced nasal cooling on migraine headaches. METHODS In this single-blind study, acute migraineurs were randomized to either nasal high-flow dry oxygen, dry air, humidified oxygen or humidified air (control) at 15 L/min for 15 min. All gases were delivered at 37°C. Severity of headache and other migraine associated symptoms (International Classification for Headache Disorders, 3rd edition criteria) were recorded before and after therapy. The primary endpoint was change in pain scores, while changes in nausea, photosensitivity and sound sensitivity scores served as secondary endpoints. A linear regression model was employed to estimate the impact of individual treatment components and their individual interactions. RESULTS Fifty-one patients (48 ± 15 years of age, 82% women) were enrolled. When compared to the control arm (humidified air), all therapeutic arms showed a significantly greater reduction in pain scores (primary endpoint) at 2 h of therapy with dry oxygen (-1.6 [95% CI -2.3, -0.9]), dry air (-1.7 [95% CI -2.6, -0.7)]), and humidified oxygen (-2.3 [95% CI -3.5, -1.1]). A significantly greater reduction in 2-h photosensitivity scores was also noted in all therapeutic arms (-1.8 [95% CI -3.2, -0.4], dry oxygen; -1.7 [95% CI -2.9, -0.4], dry air; (-2.1 [95% CI -3.6, -0.6], humidified oxygen) as compared to controls. The presence of oxygen and dryness were independently associated with significant reductions in pain and photosensitivity scores. No adverse events were reported. CONCLUSION Trans-nasal high-flow dry gas therapy may have a role in reducing migraine associated pain.Clinical Trial registration: NCT04129567.
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Affiliation(s)
- Rushil Shah
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabrizio Assis
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bharat Narasimhan
- Department of Internal Medicine, Mount Sinai St. Lukes-Roosevelt, New York, NY, USA
| | - Vahe Khachadourian
- Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Shijie Zhou
- Alliance for Cardiovascular Diagnostic and Treatment Innovation (ADVANCE), Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nauman Tariq
- Division of Neurology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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41
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A retrospective observation on 105 patients with chronic cluster headache receiving indomethacin. Neurol Sci 2021; 42:4175-4182. [PMID: 33547540 DOI: 10.1007/s10072-021-05114-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Indomethacin (IMC) as a prophylactic treatment is considered to be ineffective in cluster headache (CH). However, small series suggested the interest of IMC in CH. Some authors support that an IMC test is useful in all trigeminal autonomic cephalalgias. We described clinical features of IMC responders in a retrospective cohort of chronic cluster headache (CCH). METHODS This single-center and retrospective study was conducted in a tertiary care specialist headache center in France. Patients were selected between January 2007 and December 2008. We included all patients fulfilling CCH criteria (ICHD-3-beta). Data were collected from medical records. We recorded all the prescriptions of IMC as a prophylactic treatment. Responders were defined by 50% reduction in attack frequency; complete response was defined by disappearance of the attacks. The non-responders must have received at least 100 mg daily during 7 days. RESULTS The study consisted of 324 CCH, 121 female (37%) and 203 males (63%) with an average age at onset of 33.93 (± 14.71) years. Of the patients, 105 were treated with IMC. Thirty patients (29%) were responders. Thirty-four patients (32%) were non-responders. Responding status was undefined for 41 patients (39%). Twelve patients (11%) had a complete response. Responders were composed by 18 women (60%) and 12 men (40%) and had on average 44.89 (± 12.88) years. The minimal effective dose was 86.11 mg daily (± 48.72). DISCUSSION This study shows the interest of IMC in CCH patients. We recommend an IMC test as a third-line treatment in CCH.
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Galcanezumab: A Review in the Prevention of Migraine and Treatment of Episodic Cluster Headache. Drugs 2021; 80:893-904. [PMID: 32504377 DOI: 10.1007/s40265-020-01329-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Galcanezumab (Emgality®) is a humanized monoclonal antibody targeting the calcitonin gene-related peptide (CGRP), thereby inhibiting its physiological activity, with CGRP playing a key role in the pathophysiology of migraine and headache disorders. In pivotal phase 3 trials, recommended dosages of subcutaneous galcanezumab once monthly were significantly more effective than placebo as preventive therapy in adults with episodic (EVOLVE-1 and -2; over 6 months) or chronic (REGAIN; over 3 months) migraine (± aura), including in patients who had failed several prior preventive migraine drugs (CONQUER; over 3 months). The beneficial effects of galcanezumab preventive treatment in reducing the number of monthly migraine headache days (MHDs) and improving health-related quality of life (HR-QOL) were sustained during up to 1 year of treatment. In adults with episodic cluster headache, galcanezumab treatment was associated with a significant reduction in the weekly frequency of cluster headache attacks across weeks 1-3 compared with placebo (primary endpoint), albeit during weeks 4-8, there was a convergence of results between these treatment groups. Although further evidence from the clinical setting is required to determine its long-term safety profile, given its convenient administration regimen, efficacy and short-term tolerability profile, monthly galcanezumab represents an important emerging option for the prevention of episodic and chronic migraine (± aura) and the treatment of episodic cluster headache.
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Obermann M, Nägel S, Ose C, Sonuc N, Scherag A, Storch P, Gaul C, Böger A, Kraya T, Jansen JP, Straube A, Freilinger T, Kaube H, Jürgens TP, Diener HC, Katsarava Z, Kleinschnitz C, Holle D. Safety and efficacy of prednisone versus placebo in short-term prevention of episodic cluster headache: a multicentre, double-blind, randomised controlled trial. Lancet Neurol 2021; 20:29-37. [DOI: 10.1016/s1474-4422(20)30363-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/29/2020] [Accepted: 09/04/2020] [Indexed: 01/20/2023]
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Barloese M. Current Understanding of the Chronobiology of Cluster Headache and the Role of Sleep in Its Management. Nat Sci Sleep 2021; 13:153-162. [PMID: 33603525 PMCID: PMC7886233 DOI: 10.2147/nss.s278088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/15/2021] [Indexed: 12/11/2022] Open
Abstract
Cluster headache is uniquely rhythmic in its occurrence both diurnally and annually. This has implications for the clinical approach to the patient but also for our understanding of the role of central structures in its pathological basis. Many intrinsic and extrinsic factors seem to influence CH rhythmicity, including genetics. The proclivity for attacks to occur at night and the possible association with particular sleep phenomena, including sleep apnea, have motivated a number of studies which has improved our understanding but many questions remain unanswered. The sleep-headache interaction seems to be bidirectional and possibly both direct and indirect. The latter could involve more disperse networks of homeostatic regulation, which may better encompass recent observations. Treatment of the headache patient with concurrent sleep problems can be particularly challenging, especially considering side-effects and interactions of commonly used medications. While current treatment guidelines do not incorporate chronotherapeutic thinking, some evidence may suggest that application of such principles on an individual level may be beneficial.
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Affiliation(s)
- Mads Barloese
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging, Hvidovre Hospital, Hvidovre, Denmark.,Department of Neurology, Danish Headache Center, Rigshospitalet-Glostrup, Glostrup, Denmark
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Mapping Assessments Instruments for Headache Disorders against the ICF Biopsychosocial Model of Health and Disability. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010246. [PMID: 33396262 PMCID: PMC7795912 DOI: 10.3390/ijerph18010246] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022]
Abstract
Headache disorders have a strong impact on sufferers’ lives. However, the “content” of assessment instruments addressing concepts, such as disability and quality of life (QoL), has not comprehensively been addressed. We searched SCOPUS for research papers in which outcome measures were used in adult populations of patients with migraine, tension-type headache (TTH), and cluster headache (CH). The content of single instruments was then mapped against the International Classification of Functioning, Disability, and Health. A total of 150 papers and 26 instruments were included: 15 addressed disability or impact, two addressed work-related difficulties, and nine addressed QoL. Few instruments were commonly used across the conditions and covered domains of functioning were impact on daily life activities, homework, school, and work-related tasks, leisure time, informal and family relations, pain, emotional difficulties, energy level, and impulse control. Most of the research is based on instruments that were developed for migraine, which is critical for CH, and the impact of headache disorders on work-related activities is poorly acknowledged. Further research is needed to expand the scope of headaches impact on daily life activities, and on environmental factors relevant to headache disorders to raise knowledge on the less represented areas, e.g., TTH impact.
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Courault P, Demarquay G, Zimmer L, Lancelot S. Cluster headache: state of the art of pharmacological treatments and therapeutic perspectives. Fundam Clin Pharmacol 2020; 35:595-619. [DOI: 10.1111/fcp.12636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/13/2020] [Accepted: 12/03/2020] [Indexed: 12/26/2022]
Affiliation(s)
- Pierre Courault
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
| | | | - Luc Zimmer
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
- CERMEP‐Imaging Platform Groupement Hospitalier Est Bron France
- National Institute for Nuclear Science and Technology (INSTN) CEA Saclay France
| | - Sophie Lancelot
- Lyon Neuroscience Research Center (CRNL) Université de LyonCNRSINSERM Lyon France
- Hospices Civils de Lyon (HCL) Lyon France
- CERMEP‐Imaging Platform Groupement Hospitalier Est Bron France
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Abstract
Abstract
Purpose of review
Among the spectrum of pain conditions, cluster headache represents one of the most severe. Targeted therapies for cluster headache are evolving thus improving the available therapeutic armamentarium. A better understanding of the currently available therapies, as well as new and emerging options, may aide physicians to manage affected sufferers better by evolving treatment guidance.
Recent findings
While classic first-line medications are useful in some patients with cluster headache, they are often accompanied by significant side effects that limit their use. Recently, novel treatments with better tolerability and decreased medication interactions have proven to be effective. A remarkable example of this is the blockage of the calcitonin gene-related peptide pathway with monoclonal antibodies, which may be a key element in the future treatment of cluster headache. The sphenopalatine ganglion and vagus nerve perform a critical role in the regulation of pain and the trigeminal autonomic reflex. Neuromodulation therapies targeting these structures have shown excellent tolerability and few significant adverse events, constituting a promising form of treatment. Finally, several potential therapeutic targets are examined in this review, such as small molecule CGRP receptor antagonists, known as gepants, and serotonin receptor 5-HT1F receptor agonists: ditans.
Summary
In summary, a deepening of the understanding of cluster headache mechanisms in recent years has driven the evolution of sophisticated therapeutic approaches that could allow a new era in the treatment of this difficult condition.
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48
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Petersen AS, Lund N, Jensen RH, Barloese M. Real-life treatment of cluster headache in a tertiary headache center - results from the Danish Cluster Headache Survey. Cephalalgia 2020; 41:525-534. [PMID: 33203216 DOI: 10.1177/0333102420970455] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pharmacological treatment of cluster headache constitutes the core of clinical management, but evidence is sparse. We aimed to generate insight in the existing treatment and identify associations between clinical features and treatment response. METHODS Patients aged 18-65 diagnosed with cluster headache according to the ICHD-2 completed a questionnaire followed by a structured interview. Multiple logistic regression was used to identify associations. RESULTS The population consisted of 400 patients with an episodic: chronic ratio of 1.7:1. Episodic patients were more likely to respond to triptans (odds ratio = 1.77, confidence interval: 1.08-2.91, p = 0.023) and oxygen (odds ratio = 1.64, confidence interval: 1.05-2.57, p = 0.031) than chronic. Oxygen response was less likely if pain intensity was very severe (odds ratio = 0.53, confidence interval: 0.33-2.57, p = 0.006) and the risk of a poor response increased with disease duration (odds ratio = 0.79, confidence interval: 0.65-0.96, p = 0.016). Among current users of sumatriptan injection and oxygen, the proportion achieving 100% relief was higher with sumatriptan injection (p > 0.001) than with oxygen. No associations were identified regarding verapamil. Only 57% of current users of preventive medication responded at a 50% level. CONCLUSION Episodic cluster headache is more responsive to acute therapy than chronic. Further, sumatriptan injection was more effective than oxygen and the responder-rate was limited with verapamil. More effective acute and preventive therapies are needed for cluster headache patients.
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Affiliation(s)
- Anja Sofie Petersen
- Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Nunu Lund
- Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Rigmor Højland Jensen
- Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark
| | - Mads Barloese
- Danish Headache Center, Rigshospitalet-Glostrup, University of Copenhagen, Glostrup, Denmark.,Center of Functional and Diagnostic Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Kudrow D, Andrews JS, Rettiganti M, Oakes T, Bardos J, Gaul C, Riesenberg R, Wenzel R, Kuruppu D, Martinez J. Treatment Outcomes in Patients Treated With Galcanezumab vs Placebo: Post Hoc Analyses From a Phase 3 Randomized Study in Patients With Episodic Cluster Headache. Headache 2020; 60:2254-2264. [PMID: 33179263 PMCID: PMC7756634 DOI: 10.1111/head.14011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/01/2020] [Accepted: 10/15/2020] [Indexed: 01/03/2023]
Abstract
Background Cluster headache (CH) is a highly disabling primary headache disorder. To date, characterization of outcomes in the preventive treatment of episodic CH, including precise definitions of clinically meaningful attack frequency reduction and impact on acute treatment management, is lacking. Methods This was a Phase 3, randomized, double‐blind, placebo‐controlled study in patients (men or women aged 18‐65 years) diagnosed with episodic CH as defined by the International Classification of Headache Disorders‐3 beta criteria. In this post hoc analysis, we evaluated the median time‐to‐first occurrence of ≥50, ≥75, or 100% reduction from baseline in CH attack frequency, and impact on acute medication use. An anchor‐based assessment of clinically relevant attack frequency reduction using the Patient Global Impression of Improvement (PGI‐I) scores at Week 4 was also assessed. Results The median time‐to‐first occurrence of ≥50, ≥75, or 100% reduction from baseline in CH attacks was consistently shorter (9‐10 days sooner) with galcanezumab vs placebo (median [95% confidence interval, 95% CI]: ≥50%, 5 days [4.0 to 7.0] vs 14 days [6.0 to 19.0]; ≥75%, 11 days [7.0 to 16.0] vs 21 days [13.0 to 26.0]; 100%, 22 days [16.0 to 37.0] vs 32 days [23.0 to 34.0]). Mean reduction from baseline in the overall frequency of weekly pooled acute medication use across Weeks 1‐3 was significantly greater with galcanezumab vs placebo (11.0 vs 5.5; odds ratio, OR [95% CI]: 5.52 [1.02, 10.01]; P value = .017). Patients reporting “much better” on the PGI‐I experienced a median weekly CH attack reduction of approximately 43% from baseline across Weeks 1‐3. The overall odds of achieving an attack reduction threshold of 43% across Weeks 1‐3 was significantly higher with galcanezumab vs placebo (Weeks 1‐3: OR [95% CI], 2.60 [1.3 to 5.3]). Conclusions Faster median time‐to‐first occurrence of response rates, lower frequency of pooled acute medications use, and a greater proportion of patients achieving a response anchored by patient‐reported improvement were observed for galcanezumab vs placebo.
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Affiliation(s)
- David Kudrow
- California Medical Clinic for Headache, Santa Monica, CA, USA
| | | | | | - Tina Oakes
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Charly Gaul
- Migraine and Headache Clinic, Koenigstein, Germany
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Primaries non-migraine headaches treatment: a review. Neurol Sci 2020; 41:385-394. [PMID: 33021705 DOI: 10.1007/s10072-020-04762-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the "headache world," great attention has always been paid to migraine patients, especially for the research and development of new therapies. For the other forms of primary headaches, especially those of Chapters 2 and 3 of the classification, there are however therapies that, even if not specific, can give significant results. Tension-type headache recognizes in NSAIDs the most effective drugs to treat acute attack, while prevention is based on the use of tricyclic antidepressants and muscle relaxants. For TACs, the discussion is more complex: first of all, there are two forms of primary headache that respond absolutely to indomethacin. For these, the main problem is how to manage the possible side effects arising from prolonged treatments and possibly what to use as an alternative. For cluster headaches and short-lasting unilateral neuralgiform headache attacks, we have drugs with good efficacy as regards medical therapy, such as verapamil or lamotrigine, but in recent years, neuromodulation techniques, both surgical and non-invasive, have also been affirming themselves, which represent a more possibility for forms of headache that are often very disabling and resistant to common analgesics.
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