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Petersen AS, Lund N, Goadsby PJ, Belin AC, Wang SJ, Fronczek R, Burish M, Cho SJ, Peres MFP, Jensen RH. Recent advances in diagnosing, managing, and understanding the pathophysiology of cluster headache. Lancet Neurol 2024; 23:712-724. [PMID: 38876749 DOI: 10.1016/s1474-4422(24)00143-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 06/16/2024]
Abstract
Cluster headache, characterised by attacks of severe, recurrent, unilateral headache and ipsilateral cranial autonomic symptoms, remains a primary headache with an elusive pathophysiology. Recent advances have introduced effective treatments and broadened understanding of the clinical features of cluster headache. These features are similar in patients globally, but regional differences in prevalence and burden exist. International collaborations have led to identification of eight genetic loci associated with cluster headache. The pathophysiological mechanisms are still not fully understood but recent studies show that targeting the trigeminal autonomic reflex by neurostimulation, or targeting the neuropeptide calcitonin gene-related peptide (CGRP), might lessen the attack burden. The US Food and Drug Administration has approved galcanezumab, a monoclonal antibody targeting CGRP, as the first specific preventive treatment for episodic cluster headache. However, a preventive effect was not replicated in chronic cluster headache, and the European Medicines Agency did not approve galcanezumab, restricting its availability in Europe. Owing to the low prevalence of cluster headache, continued collaboration through multicentre clinical trials and data sharing will be imperative for further breakthroughs in understanding and management.
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Affiliation(s)
- Anja S Petersen
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nunu Lund
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter J Goadsby
- National Institute for Health and Care Research King's Clinical Research Facility, King's College London, London, UK; Department of Neurology, University of California, Los Angeles, CA, USA
| | - Andrea C Belin
- Centre for Cluster Headache, Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Shuu-Jiun Wang
- Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; College of Medicine and Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Rolf Fronczek
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Mark Burish
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, South Korea
| | - Mario F P Peres
- Hospital Israelita Albert Einstein, São Paulo, Brazil; Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da University of São Paulo, São Paulo, Brazil
| | - Rigmor H Jensen
- Danish Headache Center and Department of Neurology, Rigshospitalet-Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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San-Juan D, Velez-Jimenez K, Hoffmann J, Martínez-Mayorga AP, Melo-Carrillo A, Rodríguez-Leyva I, García S, Collado-Ortiz MÁ, Chiquete E, Gudiño-Castelazo M, Juárez-Jimenez H, Martínez-Gurrola M, Marfil A, Nader-Kawachi JA, Uribe-Jaimes PD, Darío-Vargas R, Villareal-Careaga J. Cluster headache: an update on clinical features, epidemiology, pathophysiology, diagnosis, and treatment. FRONTIERS IN PAIN RESEARCH 2024; 5:1373528. [PMID: 38524268 PMCID: PMC10957682 DOI: 10.3389/fpain.2024.1373528] [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: 01/19/2024] [Accepted: 02/19/2024] [Indexed: 03/26/2024] Open
Abstract
Cluster headache (CH) is one of the worst primary headaches that remain underdiagnosed and inappropriately treated. There are recent advances in the understanding of this disease and available treatments. This paper aims to review CH's recent clinical and pathophysiological findings, diagnosis, and treatment. We performed a narrative literature review on the socio-demographics, clinical presentations, pathophysiological findings, and diagnosis and treatment of CH. CH affects 0.1% of the population with an incidence of 2.07-9.8/100,00 person-years-habitants, a mean prevalence of 53/100,000 inhabitants (3-150/100,000 inhabitants). The male-to-female ratio remains inconclusive, as the ratio of 4.3:1 has recently been modified to 1.3-2.6, possibly due to previous misdiagnosis in women. Episodic presentation is the most frequent (80%). It is a polygenetic and multifactorial entity that involves dysfunction of the trigeminovascular system, the trigeminal autonomic reflex, and the hypothalamic networks. An MRI of the brain is mandatory to exclude secondary etiologies. There are effective and safe pharmacological treatments oxygen, sphenopalatine, and great occipital nerve block, with the heterogeneity of clinical trial designs for patients with CH divided into acute, transitional, or bridge treatment (prednisone) and preventive interventions. In conclusion, CH remains underdiagnosed, mainly due to a lack of awareness within the medical community, frequently causing a long delay in reaching a final diagnosis. Recent advances in understanding the principal risk factors and underlying pathophysiology exist. There are new therapeutic possibilities that are effective for CH. Indeed, a better understanding of this challenging pathology will continue to be a subject of research, study, and discoveries in its diagnostic and therapeutic approach.
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Affiliation(s)
- Daniel San-Juan
- Epilepsy Clinic, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | - Jan Hoffmann
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | | | - Agustín Melo-Carrillo
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Ildefonso Rodríguez-Leyva
- Department of Neurology, Hospital Central “Dr. Ignacio Morones Prieto”, and Faculty of Medicine, Universidad Autonoma de San Luis Potosí, San Luis Potosí, Mexico
| | - Silvia García
- Clinical Research Department, Centro Médico Nacional “20 de Noviembre”, ISSSTE, Mexico City, Mexico
| | | | - Erwin Chiquete
- Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición 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 León, Monterrey, Mexico
| | | | | | - Rubén Darío-Vargas
- Department of Neurology and Psychiatry, Clínica de Mérida, Merida, Mexico
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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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Pérez-Pereda S, Madera J, Munuera CS, Recio MF, Pascual J. Response to Comment on “Is conventional brain MRI useful for the diagnosis of cluste headache in patients who meet ICHD-3 criteria? Experience in three hospitals in Spain”. J Neurol Sci 2022; 438:120176. [DOI: 10.1016/j.jns.2022.120176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 11/29/2022]
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Haghdoost F. Comment on ‘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 2022; 438:120175. [DOI: 10.1016/j.jns.2022.120175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/24/2022] [Indexed: 11/28/2022]
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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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Abstract
Background Cluster headache is a highly disabling primary headache disorder which is widely described as the most painful condition a human can experience. Aim To provide an overview of the clinical characteristics, epidemiology, risk factors, differential diagnosis, pathophysiology and treatment options of cluster headache, with a focus on recent developments in the field. Methods Structured review of the literature on cluster headache. Results Cluster headache affects approximately one in 1000 of the population. It is characterised by attacks of severe unilateral head pain associated with ipsilateral cranial autonomic symptoms, and the tendency for attacks to occur with circadian and circannual periodicity. The pathophysiology of cluster headache and other primary headache disorders has recently become better understood and is thought to involve the hypothalamus and trigeminovascular system. There is good quality evidence for acute treatment of attacks with parenteral triptans and high flow oxygen; preventive treatment with verapamil; and transitional treatment with oral corticosteroids or greater occipital nerve injection. New pharmacological and neuromodulation therapies have recently been developed. Conclusion Cluster headache causes distinctive symptoms, which once they are recognised can usually be managed with a variety of established treatments. Recent pathophysiological understanding has led to the development of newer pharmacological and neuromodulation therapies, which may soon become established in clinical practice.
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Affiliation(s)
- Sanjay Cheema
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
| | - Manjit Matharu
- Headache and Facial Pain Group, University College London (UCL) Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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Abstract
PURPOSE OF REVIEW The treatment of cluster headache has evolved to include a handheld neuromodulation device and a monoclonal antibody in addition to more traditional agents. RECENT FINDINGS Galcanezumab is an approved treatment for episodic cluster headache. The non-invasive vagal nerve stimulator has been shown to be effective as a treatment for episodic cluster headache. Dedicated pituitary imaging may not be necessary with a normal MRI of the brain. Cluster headache is the most common trigeminal-autonomic cephalalgia, characterized by unilateral, frequent, debilitating attacks associated with ipsilateral autonomic symptoms. Attacks have a circadian and, often, seasonal pattern with periods of remission that can last months to years in episodic patients. Though a rare disease, an increasing number of studies have revealed novel targets for treatment. Treatment in cluster headache should focus on early intervention to reduce frequency of attacks and the length of the cycle, which improves outcomes and disability. Acute therapy is used to treat attacks, while bridging and preventive therapies are combined to reduce cycle length. Case 1: A 43-year-old man presents with the chief complaint of severe headaches. Upon general examination, he seems uncomfortable, agitated, and exhausted. He states that he hasn't "slept in over a week because of debilitating headaches." His headaches start around the same time every night: when he lays down to go to sleep. The pain is described as sharp, like a "hot poker" to his left eye. His partner has noticed that his eye droops and turns red when the pain starts. The attacks come on abruptly and prevent him from sleeping. The severe pain lasts 30 to 45 min, but he has mild-to-moderate pain that lingers for the rest of the night. He has seen his primary care physician, an allergist, and an ear, nose, and throat (ENT) specialist before coming to see a neurologist. Similar headaches occurred last year during the month of October as well. On further questioning, he reports that these headache attacks have been occurring almost yearly for the past 7 years. Each year, these headaches come on as the weather is changing and occur on a nightly basis for about 3 to 4 weeks.
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