Current and Novel Therapies for Cluster Headache: A Narrative Review

Cluster headache (CH) is an excruciating and debilitating primary headache disorder. The prevalence is up to 1.3%, and the typical onset is around age 30. Often misdiagnosed as migraine, particularly in children, the diagnosis rate of CH has been increasing among women. CH is characterized by intense unilateral pain and autonomic symptoms, significantly impacting patients' quality of life, mental health, and productivity.Genetic associations suggest a familial risk for developing CH, with lifestyle factors also potentially playing a role. The pathophysiology involves alterations in both central and peripheral nervous system, with the hypothalamus, trigeminocervical complex, and neuropeptides such as calcitonin gene-related peptide (CGRP) being implicated.Nonpharmacological treatments focus on patient education and lifestyle modifications, while pharmacological treatments include acute therapies such as oxygen and subcutaneous or nasal sumatriptan, as well as preventive therapies like verapamil, lithium, and CGRP monoclonal antibodies. Transitional options include oral corticosteroids and greater occipital nerve injections. Emerging interventional procedures offer new avenues for managing refractory cases. Noninvasive vagal nerve stimulation and occipital nerve stimulation show promise for both acute and preventive treatment. Careful consideration of safety profiles is crucial in specific populations such as pregnant patients and children.Current treatments still leave patients highly burdened by limited efficacy and side effects. Future research continues to explore novel pharmacological targets, interventional procedures, and the potential role of psychedelics in CH management. Comprehensive, multifaceted treatment strategies are essential to improve the daily functioning and quality of life for individuals with CH.

Ethnobotanical knowledge and utilization patterns of Burseraceae resins in Brazil

ETHNOPHARMACOLOGICAL RELEVANCE

Amid all the Brazilian phytodiversity, in all its shades and shapes, black and white amorphous masses glued to the barks of Burseraceae species stand out as some of the nation's most appreciated plant medicinal resources. Burseraceae resins have been used in all macroregions of Brazil, wherever they occur, for a variety of medicinal purposes. However, despite ongoing interest in them, their cultural and health relevance in the country has been underexamined.

AIM OF THE STUDY

This review aimed to illuminate the therapeutic importance and potential of Brazilian Burseraceae by assembling the ethnomedicinal, chemical, and pharmacological data available on its resins used in Brazil.

MATERIALS AND METHODS

A search for journal articles documenting local ethnomedicinal uses of Burseraceae resins and reporting chemical and pharmacological data associated with their botanical sources was conducted in ScienceDirect, Google Scholar, and PubMed databases. Books and theses were also appraised for such information.

RESULTS

At least 21 Burseraceae taxa, belonging to Protium, Trattinnickia, and Commiphora, are recorded as sources of medicinal resins in Brazil. Protium and Trattinickia yield oleoresins typically rich in mono- and triterpenoids, especially the pentacyclic triterpenoids α- and β-amyrin. Although Commiphora oleo-gum-resins are expected to differ significantly from Protium and Trattinickia oleoresins by the presence of gum fractions, they often exhibit distinct terpenoid compositional patterns, characterized by a high proportion of sesquiterpenoids and tetracyclic triterpenoids. Burseraceae resins are more frequently cited in the Brazilian ethnomedicinal literature for relieving headaches and healing wounds. Pharmacological evidence corroborates the potential of Burseraceae resins against these and some other conditions and diseases, however, further studies are needed to confirm their efficacy and safety when used topically and through inhalation-the two primary routes of administration explored for them in Brazil.

CONCLUSIONS

The present review unearths a consistent, persistent, and cross-cultural pattern of using Burseraceae resins against pain conditions. But to really tap into the Burseraceae's therapeutic potential in Brazil, we first need to address the following gaps: (a) conduct more thorough pharmacological studies, including clinical trials; (b) give more attention to the triterpenoid fraction of Burseraceae oleoresins, not only to essential oils and α- and β-amyrin; and (c) deepen our understanding of the impact of resin aging on chemical composition.

Complementary and Integrative Medicine for the Treatment of Trigeminal Neuralgia and Trigeminal Autonomic Cephalalgia

PURPOSE OF REVIEW

Trigeminal neuralgia (TN) and trigeminal autonomic cephalalgias (TACs) are both painful diseases which directly impact the branches of the trigeminal nerve, which supply the face. Patients who have experienced adverse effects, have not responded to mainstream treatments, or have a personal preference for nonmedication options, often turn to complementary and integrative medicine (CIM). The aim of this review is to discuss the efficacy and safety of CIM therapies available for the treatment of TN and TACs.

RECENT FINDINGS

Not only are there limited therapeutic options for TN and TAC patients, but also is there a proportion of patients who are intolerant to standard medical treatments. Recent findings have illustrated that 86% of patients with headache disorders utilize CIM modalities in combination with mainstream medical therapy. CIM modalities can be helpful for these diseases and have primarily been studied in combination with standard medical therapy. There is limited evidence for CIM and behavioral therapies in managing these conditions, and more research is needed to confirm which therapies are safe and effective.

The journey of boswellic acids from synthesis to pharmacological activities

There has been a lot of interest in using naturally occurring substances to treat a wide variety of chronic disorders in recent years. From the gum resin of Boswellia serrata and Boswellia carteri, the pentacyclic triterpene molecules known as boswellic acid (BA) are extracted. We aimed to provide a detailed overview of the origins, chemistry, synthetic derivatives, pharmacokinetic, and biological activity of numerous Boswellia species and their derivatives. The literature searched for reports of B. serrata and isolated BAs having anti-cancer, anti-microbial, anti-inflammatory, anti-arthritic, hypolipidemic, immunomodulatory, anti-diabetic, hepatoprotective, anti-asthmatic, and clastogenic activities. Our results revealed that the cytotoxic and anticancer effects of B. serrata refer to its triterpenoid component, including BAs. Three-O-acetyl-11-keto-BA was the most promising cytotoxic molecule among tested substances. Activation of caspases, upregulation of Bax expression, downregulation of nuclear factor-kappa B (NF-kB), and stimulation of poly (ADP)-ribose polymerase (PARP) cleavage are the primary mechanisms responsible for cytotoxic and antitumor effects. Evidence suggests that BAs have shown promise in combating a wide range of debilitating disease conditions, including cancer, hepatic, inflammatory, and neurological disorders.

[Complementary and supplementary procedures in the treatment of headache]

In Germany, headache is one of the illnesses that most frequently leads to health impairments and to consultation with physicians. Even in children, headache is often associated with restricted activities of daily life. Nevertheless, the level of care for headache disorders is disproportionate to the medical needs. As a result, patients regularly use complementary and supportive therapeutic procedures. This review shows the procedures currently used for primary headache in childhood and adulthood, the methodological approaches and existing scientific evidence. The safety of the therapeutic options is also classified. These methods include physiotherapy, neural therapy, acupuncture, homeopathy, phytotherapy and the intake of dietary supplements. For children and adolescents with headaches, there are studies in the field of dietary supplements for coenzyme Q10, riboflavin, magnesium and vitamin D, which indicate specific effects in the reduction of headaches.

Efficacy of Boswellia serrata Extract and/or an Omega-3-Based Product for Improving Pain and Function in People Older Than 40 Years with Persistent Knee Pain: A Randomized Double-Blind Controlled Clinical Trial

A single-center, randomized, double-blind, controlled clinical trial with four arms was conducted in healthy subjects with persistent knee discomfort (pain intensity on 1-10 cm visual analog scale (VAS) > 3) aged 40 years and older treated with a dietary supplement for 8 weeks. The study groups were Boswellia serrata extract (n = 29), an omega-3-based product (AvailOm® 50 High EPA) (n = 31), Boswellia + AvailOm® (n = 30), and placebo (n = 30). The intake of Boswellia + AvailOm® improved the quality of life (QoL) (WOMAC index) and some variables of muscle strength. Statistically significant differences between the AvailOm® and the placebo groups in the decrease of pain intensity were found. Weekly VAS scores showed a significant decrease in pain perception when comparing the AvailOm® product to the placebo, with the lowest VAS scores at week 8. Consumption of Boswellia improved sleep latency. The time to perform the Up and Go test decreased after the intake of AvailOm®. There was an increase in the omega-3 fatty acids, with the greatest increase in the Boswellia + AvailOm® group. AvailOm® was safe and effective in reducing pain and improving the QoL and functionality of subjects over 40 years with persistent knee pain.

Boswellia serrata extract shows cognitive benefits in a double-blind, randomized, placebo-controlled pilot clinical trial in individuals who suffered traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a major cause of death and disability. TBI can result in neuropsychiatric and cognitive problems as well as neurodegenerative pathologies that can appear right after or develop and persist years after injury.

METHOD

We conducted a double-blind, randomized, placebo-controlled clinical trial on patients who suffered from TBI three months to three years ago. The patients were randomized to placebo (n = 34) or K-Vie™ group (n = 46) for a treatment period of 3 months. The main primary outcomes include cognitive assessment in the Rey Auditory Verbal Learning Test-Recognition Test (RAVLT), Wechsler adult intelligence Digit Symbol Substitution Test (DSST) and trail-making test part B (TMT-B). Assessments were performed at baseline and at the month 3 follow-up visit. Linear mixed models were carried out to evaluate cognitive changes from baseline across all cognitive assessment tests.

RESULT

The current study showed significant (p < 0.05) improvement in cognitive function of patients who were given K-Vie™ compared with placebo across the RAVLT, DSST and TMT-B performance assessments. A larger cohort would be beneficial to further confirm the clinical utility of K-Vie™ and assess its effects in acute phases of TBI.

Amazonian medicinal smokes: Chemical analysis of Burseraceae pitch (breu) oleoresin smokes and insights into their use on headache

ETHNOPHARMACOLOGICAL RELEVANCE

In Latin American Traditional Medicine, the use of Burseraceae oleoresins for headache relief is widespread. In the quilombola (maroon) communities of the municipality of Oriximiná, Pará State, Brazil, Burseraceae oleoresins are burned as incenses to treat headache; an effect attained by inhaling the smokes.

AIM OF THE STUDY

This study was designed to investigate the scientific rationale behind the use of Burseraceae pitch oleoresin smokes on headache by identifying its chemical constituents and discussing whether they could be beneficial for headache treatment.

MATERIALS AND METHODS

Two samples of pitch oleoresins were purchased from Amazonian public markets; one of them marketed as "breu preto" (black pitch), and the other as "breu branco" (white pitch). The smoke headspaces produced upon burning these oleoresins were collected and analysed by GC-MS. For comparative purposes, the triterpenoid fingerprints of the oleoresins' dichloromethane extracts and profiles of the essential oils were also obtained by GC-MS - and GC-FID, in the case of the essential oils.

RESULTS

A total of 32 compounds were detected in black and white pitch oleoresin smokes. All smoke headspaces of the pitch oleoresins shared the presence of volatile terpenoids (e.g., α-terpineol) and triterpenoids (e.g., α-amyrin, β-amyrin, α-amyrone, and β-amyrone). These compounds were also present in the crude resins and could potentially be responsible for anti-inflammatory, antinociceptive and analgesic effects on headache.

CONCLUSIONS

The pharmacological data on the terpenoids detected in the Burseraceae pitch smokes strongly support their traditional use for headache, but their actual effects upon inhalation have yet to be determined.

Headaches in the medieval Medical School of Salerno

PREMISE

Headaches are a serious public health concern of our days, affecting about 50% of the world's adult population. However, such a plague is not limited to the modern era, since ancient archaeological, written, religious and cultural evidences testify to countless attempts to face such disorders from medical, neurosurgical, psychological and sociological perspectives.

BACKGROUND

Substantially, the Hippocratic and Galenic theories about headache physiopathology remained predominant up to the 17th century, when the vascular theory of migraine was introduced by Thomas Willis and then evolved into the actual neurovascular hypothesis. The medieval Medical School of Salerno, in southern Italy, where the Greco-Roman medical doctrine was deeply affected by the medio-oriental influence, gave particular attention to both prevention and treatment of headaches.

CONCLUSION

The texts of the School, a milestone in the literature of medicine, translated into different languages and widespread throughout Europe for centuries, provide numerous useful recipes and ingredients with an actually proven pharmacological efficacy.

Gastroprotective herbs for headache management in Persian medicine: A comprehensive review

The gut-brain axis is a bidirectional communication system that exists between the brain and gut. Several studies claimed that some types of headaches are associated with various gastrointestinal (GI) disorders. In Persian medicine (PM), physicians believed that gastric disturbances could stimulate headache and introduced some herbs for boosting gastric function as a therapeutic remedy for headache. Here we review the current evidence for the gastroprotective and antiheadache effects of herbs used in PM. Herbs used for their gastrotonic effects in PM were identified from selected Persian medical and pharmaceutical textbooks. PubMed, Scopus and Google Scholar were used to search for contemporary scientific evidence relating to the gastric and neurologic effects of these plants. A total of 24 plants were recorded from the selected sources included in this review, most of which belonged to the Rosaceae family. Phyllanthus emblica, Zingiber officinale, Boswellias errata, Punica granatum and Hypericum perforatum had the most recent studies related to GI disorder and headache, while current research about quince, rose, apple, hawthorn and pear was limited. Reducing Helicobacter pylori growth, gastritis, erosion of the stomach lining, hemorrhage and perforation, improving gastric mucosal resistance, antisecretary, antiulcer, antipyretic, analgesic, sedative, anxiolytic, anti-inflammatory, anticonvulsant, neuroprotective and antioxidant effects as well as improvement in memory scores were some of the gastrotonic and neuroprotective mechanisms described in the current research. These results confirmed that medicinal plants prescribed in PM may improve headache in patients through the management of GI abnormalities. However, further studies are recommended to investigate the efficacy and safety of the mentioned medicinal plants.

Nutraceuticals in Acute and Prophylactic Treatment of Migraine

OPINION STATEMENT

People who suffer from headaches often prefer nutraceutical treatment over traditional pharmacological approaches, due to fear of possible side effects, drug dependence, or addiction. Since treatment with nutraceuticals does not require a doctor's prescription, many patients rely on their own judgment as to when and which one to take, often without consultation or guidance from their physician. Some physicians could provide information about potential efficacy and side effects of various products, but many are not familiar with the nutraceuticals. Widespread skepticism persists among doctors about the effectiveness of these treatments. This is largely due to the lack of rigorous clinical studies. However, even when incontrovertible scientific evidence exists, many physicians remain distrustful of the evidence. The following review summarizes randomized controlled trials of some of the most commonly used non-pharmacological treatments, including magnesium, coenzyme Q10, riboflavin (vitamin B2), petasites, and feverfew (Table 1).