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Burish MJ, Guirguis AB, Schindler EAD. Managing Cluster Headache in Patients with Medical, Psychiatric, and Surgical Comorbidities. Curr Neurol Neurosci Rep 2024; 24:439-452. [PMID: 39017830 DOI: 10.1007/s11910-024-01362-x] [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: 07/06/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE OF REVIEW What should a provider know about medications and other treatments in patients with cluster headache who have medical, psychiatric, and surgical comorbidities? What conversations should providers have with patients about living with and managing cluster headache? RECENT FINDINGS While the number of treatments used in cluster headache is relatively small, numerous considerations were identified related to managing patients with comorbidities. Many of these touch on cardiac, cardiovascular, and cerebrovascular health, but full histories are needed to guide safe and effective treatment. Both older and newer treatments may be contraindicated in certain patients with cluster headache or should be considered carefully. In addition to incorporating medical, psychiatric, and surgical histories in the management plan, collaboration with other providers may be beneficial. Providers should also inquire about patient practices and discuss participation in clinical trials that might be a good fit for the individual.
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Affiliation(s)
- Mark J Burish
- Department of Neurosurgery, McGovern Medical School at UTHealth Houston, Houston, TX, USA
| | - Alexander B Guirguis
- Veteran Health Administration Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Emmanuelle A D Schindler
- Veteran Health Administration Headache Center of Excellence, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
- VA Connecticut Healthcare System, Neurology Service, MS 127, 950 Campbell Avenue, West Haven, CT, 06516, USA.
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Burish M. Cluster Headache, SUNCT, and SUNA. Continuum (Minneap Minn) 2024; 30:391-410. [PMID: 38568490 DOI: 10.1212/con.0000000000001411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE This article reviews the epidemiology, clinical features, differential diagnosis, pathophysiology, and management of three types of trigeminal autonomic cephalalgias: cluster headache (the most common), short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT), and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). LATEST DEVELOPMENTS The first-line treatments for trigeminal autonomic cephalalgias have not changed in recent years: cluster headache is managed with oxygen, triptans, and verapamil, and SUNCT and SUNA are managed with lamotrigine. However, new successful clinical trials of high-dose prednisone, high-dose galcanezumab, and occipital nerve stimulation provide additional options for patients with cluster headache. Furthermore, new genetic and imaging tests in patients with cluster headache hold promise for a better understanding of its pathophysiology. ESSENTIAL POINTS The trigeminal autonomic cephalalgias are a group of diseases that appear similar to each other and other headache disorders but have important differences. Proper diagnosis is crucial for proper treatment.
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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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Han C, Lim JY, Koike N, Kim SY, Ono K, Tran CK, Mangutov E, Kim E, Zhang Y, Li L, Pradhan AA, Yagita K, Chen Z, Yoo SH, Burish MJ. Regulation of headache response and transcriptomic network by the trigeminal ganglion clock. Headache 2024; 64:195-210. [PMID: 38288634 PMCID: PMC10961824 DOI: 10.1111/head.14670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 12/06/2023] [Accepted: 12/20/2023] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To characterize the circadian features of the trigeminal ganglion in a mouse model of headache. BACKGROUND Several headache disorders, such as migraine and cluster headache, are known to exhibit distinct circadian rhythms of attacks. The circadian basis for these rhythmic pain responses, however, remains poorly understood. METHODS We examined trigeminal ganglion ex vivo and single-cell cultures from Per2::LucSV reporter mice and performed immunohistochemistry. Circadian behavior and transcriptomics were investigated using a novel combination of trigeminovascular and circadian models: a nitroglycerin mouse headache model with mechanical thresholds measured every 6 h, and trigeminal ganglion RNA sequencing measured every 4 h for 24 h. Finally, we performed pharmacogenomic analysis of gene targets for migraine, cluster headache, and trigeminal neuralgia treatments as well as trigeminal ganglion neuropeptides; this information was cross-referenced with our cycling genes from RNA sequencing data to identify potential targets for chronotherapy. RESULTS The trigeminal ganglion demonstrates strong circadian rhythms in both ex vivo and single-cell cultures, with core circadian proteins found in both neuronal and non-neuronal cells. Using our novel behavioral model, we showed that nitroglycerin-treated mice display circadian rhythms of pain sensitivity which were abolished in arrhythmic Per1/2 double knockout mice. Furthermore, RNA-sequencing analysis of the trigeminal ganglion revealed 466 genes that displayed circadian oscillations in the control group, including core clock genes and clock-regulated pain neurotransmitters. In the nitroglycerin group, we observed a profound circadian reprogramming of gene expression, as 331 of circadian genes in the control group lost rhythm and another 584 genes gained rhythm. Finally, pharmacogenetics analysis identified 10 genes in our trigeminal ganglion circadian transcriptome that encode target proteins of current medications used to treat migraine, cluster headache, or trigeminal neuralgia. CONCLUSION Our study unveiled robust circadian rhythms in the trigeminal ganglion at the behavioral, transcriptomic, and pharmacogenetic levels. These results support a fundamental role of the clock in pain pathophysiology. PLAIN LANGUAGE SUMMARY Several headache diseases, such as migraine and cluster headache, have headaches that occur at the same time each day. We learned that the trigeminal ganglion, an important pain structure in several headache diseases, has a 24-hour cycle that might be related to this daily cycle of headaches. Our genetic analysis suggests that some medications may be more effective in treating migraine and cluster headache when taken at specific times of the day.
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Affiliation(s)
- Chorong Han
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Ji Ye Lim
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Nobuya Koike
- Department of Physiology and Systems Bioscience, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Sun Young Kim
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Kaori Ono
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Celia K. Tran
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Elizaveta Mangutov
- Center for Clinical Pharmacology, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Eunju Kim
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Yanping Zhang
- Center for Clinical Pharmacology, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Lingyong Li
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Amynah A. Pradhan
- Center for Clinical Pharmacology, Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Kazuhiro Yagita
- Department of Physiology and Systems Bioscience, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Zheng Chen
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Seung-Hee Yoo
- Department of Biochemistry and Molecular Biology, UTHealth Houston, Houston, Texas, USA
| | - Mark J. Burish
- Department of Neurosurgery, UTHealth Houston, Houston, Texas, USA
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Vandenbussche N, Van Der Donckt J, De Brouwer M, Steenwinckel B, Stojchevska M, Ongenae F, Van Hoecke S, Paemeleire K. Patients with chronic cluster headache may show reduced activity energy expenditure on ambulatory wrist actigraphy recordings during daytime attacks. Brain Behav 2024; 14:e3360. [PMID: 38376015 PMCID: PMC10761329 DOI: 10.1002/brb3.3360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVE To investigate the changes in activity energy expenditure (AEE) throughout daytime cluster headache (CH) attacks in patients with chronic CH and to evaluate the usefulness of actigraphy as a digital biomarker of CH attacks. BACKGROUND CH is a primary headache disorder characterized by attacks of severe to very severe unilateral pain (orbital, supraorbital, temporal, or in any combination of these sites), with ipsilateral cranial autonomic symptoms and/or a sense of restlessness or agitation. We hypothesized increased AEE from hyperactivity during attacks measured by actigraphy. METHODS An observational study including patients with chronic CH was conducted. During 21 days, patients wore an actigraphy device on the nondominant wrist and recorded CH attack-related data in a dedicated smartphone application. Accelerometer data were used for the calculation of AEE before and during daytime CH attacks that occurred in ambulatory settings, and without restrictions on acute and preventive headache treatment. We compared the activity and movements during the pre-ictal, ictal, and postictal phases with data from wrist-worn actigraphy with time-concordant intervals during non-headache periods. RESULTS Four patients provided 34 attacks, of which 15 attacks met the eligibility criteria for further analysis. In contrast with the initial hypothesis of increased energy expenditure during CH attacks, a decrease in movement was observed during the pre-ictal phase (30 min before onset to onset) and during the headache phase. A significant decrease (p < .01) in the proportion of high-intensity movement during headache attacks, of which the majority were oxygen-treated, was observed. This trend was less present for low-intensity movements. CONCLUSION The unexpected decrease in AEE during the pre-ictal and headache phase of daytime CH attacks in patients with chronic CH under acute and preventive treatment in ambulatory settings has important implications for future research on wrist actigraphy in CH.
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Affiliation(s)
- Nicolas Vandenbussche
- Department of NeurologyGhent University HospitalGhentBelgium
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health SciencesGhent UniversityGhentBelgium
| | | | | | | | | | | | | | - Koen Paemeleire
- Department of NeurologyGhent University HospitalGhentBelgium
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health SciencesGhent UniversityGhentBelgium
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Benkli B, Kim SY, Koike N, Han C, Tran CK, Silva E, Yan Y, Yagita K, Chen Z, Yoo SH, Burish MJ. Circadian Features of Cluster Headache and Migraine: A Systematic Review, Meta-analysis, and Genetic Analysis. Neurology 2023; 100:e2224-e2236. [PMID: 36990725 PMCID: PMC10259280 DOI: 10.1212/wnl.0000000000207240] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/16/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Cluster headache and migraine have circadian features at multiple levels (cellular, systems, and behavioral). A thorough understanding of their circadian features informs their pathophysiologies. METHODS A librarian created search criteria in MEDLINE Ovid, Embase, PsycINFO, Web of Science, and Cochrane Library. Two physicians independently performed the remainder of the systematic review/meta-analysis using Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Separate from the systematic review/meta-analysis, we performed a genetic analysis for genes with a circadian pattern of expression (clock-controlled genes or CCGs) by cross-referencing genome-wide association studies (GWASs) of headache, a nonhuman primate study of CCGs in a variety of tissues, and recent reviews of brain areas relevant in headache disorders. Altogether, this allowed us to catalog circadian features at the behavioral level (circadian timing, time of day, time of year, and chronotype), systems level (relevant brain areas where CCGs are active, melatonin and corticosteroid levels), and cellular level (core circadian genes and CCGs). RESULTS For the systematic review and meta-analysis, 1,513 studies were found, and 72 met the inclusion criteria; for the genetic analysis, we found 16 GWASs, 1 nonhuman primate study, and 16 imaging reviews. For cluster headache behavior, meta-analyses showed a circadian pattern of attacks in 70.5% (3,490/4,953) of participants across 16 studies, with a clear circadian peak between 21:00 and 03:00 and circannual peaks in spring and autumn. Chronotype was highly variable across studies. At the systems level, lower melatonin and higher cortisol levels were reported in cluster headache participants. At the cellular level, cluster headache was associated with core circadian genes CLOCK and REV-ERBα, and 5 of the 9 cluster headache susceptibility genes were CCGs. For migraine behavior, meta-analyses showed a circadian pattern of attacks in 50.1% (2,698/5,385) of participants across 8 studies, with a clear circadian trough between 23:00 and 07:00 and a broad circannual peak between April and October. Chronotype was highly variable across studies. At the systems level, urinary melatonin levels were lower in participants with migraine and even lower during an attack. At the cellular level, migraine was associated with core circadian genes CK1δ and RORα, and 110 of the 168 migraine susceptibility genes were CCGs. DISCUSSION Cluster headache and migraine are highly circadian at multiple levels, reinforcing the importance of the hypothalamus. This review provides a pathophysiologic foundation for circadian-targeted research into these disorders. TRIAL REGISTRATION INFORMATION The study was registered with PROSPERO (registration number CRD42021234238).
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Affiliation(s)
- Barlas Benkli
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Sun Young Kim
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Nobuya Koike
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Chorong Han
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Celia K Tran
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Emma Silva
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Yuanqing Yan
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Kazuhiro Yagita
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Zheng Chen
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Seung-Hee Yoo
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston
| | - Mark J Burish
- From the Departments of Neurology (B.B.), Biochemistry and Molecular Biology (S.Y.K., C.H., C.T., Z.C., S.-H.Y.), and Neurosurgery (Y.Y., M.J.B.), UTHealth Houston; Department of Physiology and Systems Bioscience (N.K., K.Y.), Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan; and Texas Medical Center Library (E.S.), The University of Texas Health Science Center at Houston.
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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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Al-Karagholi MAM, Peng KP, Petersen AS, De Boer I, Terwindt GM, Ashina M. Debate: Are cluster headache and migraine distinct headache disorders? J Headache Pain 2022; 23:151. [PMID: 36447146 PMCID: PMC9706960 DOI: 10.1186/s10194-022-01504-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/29/2022] [Indexed: 11/30/2022] Open
Abstract
Cluster headache and migraine are regarded as distinct primary headaches. While cluster headache and migraine differ in multiple aspects such as gender-related and headache specific features (e.g., attack duration and frequency), both show clinical similarities in trigger factors (e.g., alcohol) and treatment response (e.g., triptans). Here, we review the similarities and differences in anatomy and pathophysiology that underlie cluster headache and migraine, discuss whether cluster headache and migraine should indeed be considered as two distinct primary headaches, and propose recommendations for future studies. Video recording of the debate held at the 1st International Conference on Advances in Migraine Sciences (ICAMS 2022, Copenhagen, Denmark) is available at https://www.youtube.com/watch?v=uUimmnDVTTE .
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Affiliation(s)
- Mohammad Al-Mahdi Al-Karagholi
- grid.5254.60000 0001 0674 042XDanish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, DK-2600 Glostrup, Denmark
| | - Kuan-Po Peng
- grid.13648.380000 0001 2180 3484Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Sofie Petersen
- grid.5254.60000 0001 0674 042XDanish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, DK-2600 Glostrup, Denmark
| | - Irene De Boer
- grid.10419.3d0000000089452978Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Gisela M. Terwindt
- grid.10419.3d0000000089452978Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Messoud Ashina
- grid.5254.60000 0001 0674 042XDanish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Valdemar Hansen Vej 5, DK-2600 Glostrup, Denmark
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9
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Iser C, Arca K. Headache and Autonomic Dysfunction: a Review. Curr Neurol Neurosci Rep 2022; 22:625-634. [PMID: 35994191 DOI: 10.1007/s11910-022-01225-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW We explore the anatomy of the central and peripheral autonomic pathways involved in primary headache as well as the mechanisms for secondary headache associated with disorders of the autonomic nervous system. The prevalence and clinical presentation of cranial and systemic autonomic symptoms in these conditions will be discussed, with a focus on recent studies. RECENT FINDINGS Several small studies have utilized the relationship between headache and the autonomic nervous system to identify potential biomarkers to aid in diagnosis of migraine and cluster headache. Headache in postural orthostatic tachycardia syndrome (POTS) has also been further characterized, particularly in its association with orthostatic headache and spontaneous intracranial hypotension (SIH). This review examines the pathophysiology of primary and secondary headache disorders in the context of the autonomic nervous system. Mechanisms of headache associated with systemic autonomic disorders are also reviewed.
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Affiliation(s)
- Courtney Iser
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA
| | - Karissa Arca
- Department of Neurology, Mayo Clinic Scottsdale, Scottsdale, AZ, USA.
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Wei DY, Goadsby PJ. Recent Advances and Updates in Trigeminal Autonomic Cephalalgias. Semin Neurol 2022; 42:474-478. [PMID: 36323300 DOI: 10.1055/s-0042-1758043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Trigeminal autonomic cephalalgias (TACs) are discrete primary headache disorders, characterized by severe unilateral head pain, typically trigeminal distribution, with ipsilateral cranial autonomic symptoms. The conditions within this group are hemicrania continua, cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing and short-lasting unilateral neuralgiform headache with autonomic symptoms. Several advances have been made in understanding the pathogenesis and evolving treatment options in TACs. This review will outline the advances and updates in each TAC.
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Affiliation(s)
- Diana Y Wei
- Department of Neurology, King's College Hospital, London, United Kingdom
- Headache Group, Wolfson Centre for Age-Related Diseases, King's College London, London, United Kingdom
| | - Peter J Goadsby
- Headache Group, Wolfson Centre for Age-Related Diseases, King's College London, London, United Kingdom
- NIHR King's Clinical Research Facility, Biomedical Research Centre, King's College Hospital, London, United Kingdom
- Department of Neurology, University of California, Los Angeles, California
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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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Wei DY, O'Daly O, Zelaya FO, Goadsby PJ. Areas of cerebral blood flow changes on arterial spin labelling with the use of symmetric template during nitroglycerin triggered cluster headache attacks. Neuroimage Clin 2022; 33:102920. [PMID: 34972033 PMCID: PMC8724947 DOI: 10.1016/j.nicl.2021.102920] [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: 10/05/2021] [Revised: 12/06/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Abstract
Cluster headache is a severe unilateral primary headache disorder; however, the brain is asymmetric, therefore using a symmetric template before flipping in the x-axis allows for ipsilateral analysis of attacks without loss of coherence across the group. Increases in cerebral blood flow beyond pain anticipation, processing and modulation areas, including hypothalamic regions and ipsilateral pons, have a crucial pathophysiological role in cluster headache attacks. The pain experienced during cluster headache attacks is so severe that it “switches off” areas involved in the default brain network.
Background Cluster headache is a rare, strictly unilateral, severe episodic primary headache disorder. Due to the unpredictable and episodic nature of the attacks, nitroglycerin has been used to trigger attacks for research purposes to further our understanding of cluster headache pathophysiology. Objectives We aimed to identify regions of significant cerebral blood flow (CBF) changes during nitroglycerin triggered cluster headache attacks, using MRI with arterial spin labelling (ASL). Methods Thirty-three subjects aged 18–60 years with episodic and chronic cluster headache were recruited and attended an open clinical screening visit without scanning to receive an intravenous nitroglycerin infusion (0.5 μg/kg/min over 20 min). Those for whom nitroglycerin successfully triggered a cluster headache attack, were invited to attend two subsequent scanning visits. They received either single-blinded intravenous nitroglycerin (0.5 μg/kg/min) or an equivalent volume of single-blinded intravenous 0.9% sodium chloride over a 20-minute infusion. Whole-brain CBF maps were acquired using a 3 Tesla MRI scanner pre-infusion and post-infusion. As cluster headache is a rare condition and purely unilateral disorder, an analysis strategy to ensure all the image data corresponded to symptomatology in the same hemisphere, without losing coherence across the group, was adopted. This consisted of spatially normalising all CBF maps to a standard symmetric reference template before flipping the images about the anterior-posterior axis for those CBF maps of subjects who experienced their headache in the right hemisphere. This procedure has been employed in previous studies and generated a group data set with expected features on the left hemisphere only. Results Twenty-two subjects successfully responded to the nitroglycerin infusion and experienced triggered cluster headache attacks. A total of 20 subjects completed the placebo scanning visit, 20 completed the nitroglycerin scanning visit, and 18 subjects had completed both the nitroglycerin and placebo scanning visits. In a whole-brain analysis, we identified regions of significantly elevated CBF in the medial frontal gyrus, superior frontal gyrus, inferior frontal gyrus and cingulate gyrus, ipsilateral to attack side, in CBF maps acquired during cluster headache attack; compared with data from the placebo session. We also identified significantly reduced CBF in the precuneus, cuneus, superior parietal lobe and occipital lobe contralateral to the attack side. Of particular interest to this field of investigation, both the hypothalamus and ipsilateral ventral pons showed higher CBF in a separate region of interest analysis. Conclusion Our data demonstrate that severe cluster headache leads to significant increases in regional cerebral perfusion, likely to reflect changes in neuronal activity in several regions of the brain, including the hypothalamus and the ventral pons. These data contribute to our understanding of cluster headache pathophysiology; and suggest that non-invasive ASL technology may be valuable in future mechanistic studies of this debilitating condition.
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Affiliation(s)
- Diana Y Wei
- Headache Group, Wolfson Centre for Age-Related Diseases, King's College London, UK; NIHR Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK
| | - Owen O'Daly
- Centre for Neuroimaging Sciences, Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Fernando O Zelaya
- Centre for Neuroimaging Sciences, Department of Neuroimaging, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Peter J Goadsby
- Headache Group, Wolfson Centre for Age-Related Diseases, King's College London, UK; NIHR Wellcome Trust King's Clinical Research Facility, King's College Hospital, London, UK; Department of Neurology, University of California, Los Angeles, CA, USA.
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Karsan N, Nagaraj K, Goadsby PJ. Cranial autonomic symptoms: prevalence, phenotype and laterality in migraine and two potentially new symptoms. J Headache Pain 2022; 23:18. [PMID: 35093009 PMCID: PMC8903520 DOI: 10.1186/s10194-022-01389-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/12/2022] [Indexed: 11/12/2022] Open
Abstract
Background Whilst cranial autonomic symptoms (CAS) are typically associated with trigeminal autonomic cephalalgias (TAC’s), they have also been reported in migraine. Identification and understanding of these symptoms in migraine is important to ensure timely diagnosis and effective management. Methods Migraineurs seen in a tertiary headache service between 2014 and 2018 (n = 340): cohort one, and a separate cohort of headache patients seen between 2014-May 2021 reporting voice change, or throat swelling, or both, as CAS were selected (n = 64): cohort two. We performed a service evaluation of our records regarding age, sex, diagnosis, headache and CAS frequency and laterality as acquired from the first consultation, during which a detailed headache history is taken by a headache trained physician. Results Cohort 1: Mean age 43 (range 14–94, SD 15). The most common diagnosis was chronic migraine (78%). Median monthly headache frequency was 26 days (IQR 15–75). At least one CAS was reported in 74%, with a median of two (IQR 0–3). The most common were nasal congestion (32%), lacrimation (31%) and aural fullness (25%). Most patients reported their most common headache as unilateral (80%) and with it strictly unilateral CAS (64%). There was a positive association between headache and CAS laterality (χ21 = 20.7, P < 0.001), with a positive correlation between baseline headache frequency and number of CAS reported (r = 0.11, P = 0.047). Cohort two: mean age 49 (range 23–83, SD 14). Diagnoses were chronic migraine (50%), chronic cluster headache (11%), undifferentiated continuous lateralised headache (9%), SUNCT/SUNA (8%), hemicrania continua (8%), episodic migraine (8%), episodic cluster headache (3%) and trigeminal neuropathies (3%). Most (89%) described trigeminal distribution pain; 25% involving all three divisions. Throat swelling was reported by 54, voice change by 17, and both by 7. The most common CAS reported were lacrimation (n = 47), facial swelling (n = 45) and rhinorrhoea (n = 37). There was significant agreement between the co-reporting of throat swelling (χ21 = 7.59, P = 0.013) and voice change (χ21 = 6.49, P = 0.02) with aural fullness. Conclusions CAS are common in migraine, are associated with increasing headache frequency and tend to lateralise with headache. Voice change and throat swelling should be recognized as possible parasympathetically-mediated CAS. They may be co-associated and associated with aural fullness, suggesting a broadly somatotopic endophenotype.
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Affiliation(s)
- Nazia Karsan
- Headache Group, Division of Neuroscience, Wolfson Centre for Age Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley Biomedical Research Centre, King's College Hospital, London, UK
| | - Karthik Nagaraj
- Department of Neurology, Bangalore Medical College and Research Institute, Bangalore, India
| | - Peter J Goadsby
- Headache Group, Division of Neuroscience, Wolfson Centre for Age Related Diseases, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. .,South London and Maudsley Biomedical Research Centre, King's College Hospital, London, UK. .,Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA.
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Cluster headache pathophysiology - insights from current and emerging treatments. Nat Rev Neurol 2021; 17:308-324. [PMID: 33782592 DOI: 10.1038/s41582-021-00477-w] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2021] [Indexed: 02/01/2023]
Abstract
Cluster headache is a debilitating primary headache disorder that affects approximately 0.1% of the population worldwide. Cluster headache attacks involve severe unilateral pain in the trigeminal distribution together with ipsilateral cranial autonomic features and a sense of agitation. Acute treatments are available and are effective in just over half of the patients. Until recently, preventive medications were borrowed from non-headache indications, so management of cluster headache is challenging. However, as our understanding of cluster headache pathophysiology has evolved on the basis of key bench and neuroimaging studies, crucial neuropeptides and brain structures have been identified as emerging treatment targets. In this Review, we provide an overview of what is known about the pathophysiology of cluster headache and discuss the existing treatment options and their mechanisms of action. Existing acute treatments include triptans and high-flow oxygen, interim treatment options include corticosteroids in oral form or for greater occipital nerve block, and preventive treatments include verapamil, lithium, melatonin and topiramate. We also consider emerging treatment options, including calcitonin gene-related peptide antibodies, non-invasive vagus nerve stimulation, sphenopalatine ganglion stimulation and somatostatin receptor agonists, discuss how evidence from trials of these emerging treatments provides insights into the pathophysiology of cluster headache and highlight areas for future research.
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