Cluster headache: focus on emerging therapies

Phenotype of Cluster Headache: Clinical Variability, Persisting Pain Between Attacks, and Comorbidities-An Observational Cohort Study in 825 Patients

INTRODUCTION

Cluster headaches can occur with considerable clinical variability. The inter- and intra-individual variability could contribute to the fact that the clinical headache phenotype is not captured by too strict diagnostic criteria, and that the diagnosis and the effective therapy are thereby delayed. The aim of the study was to analyze the severity and extent of the clinical symptoms of episodic and chronic cluster headaches with regard to their variability and to compare them with the requirements of the International Classification of Headache Disorders 3rd edition (ICHD-3) diagnostic criteria.

METHODS

The study was carried out as a cross-sectional analysis of 825 patients who had been diagnosed with cluster headaches by their physician. Using an online questionnaire, standardized questions on sociodemographic variables, clinical features of the cluster headache according to ICHD-3, and accompanying clinical symptoms were recorded.

RESULTS

The majority of patients with cluster headaches have clinical features that are mapped by the diagnostic criteria of ICHD-3. However, due to the variability of the symptoms, there is a significant proportion of clinical phenotypes that are not captured by the ICHD-3 criteria for cluster headaches. In addition, change in the side of the pain between the cluster episodes, pain location, as well as persisting pain between the attacks is not addressed in the ICHD-3 criteria. In the foreground of the comorbidities are psychological consequences in the form of depression, sleep disorders, and anxiety.

CONCLUSIONS

The variability of the phenotype of cluster headaches can preclude some patients from receiving an appropriate diagnosis and effective therapy if the diagnostic criteria applied are too strict. The occurrence of persisting pain between attacks should also be diagnostically evaluated due to its high prevalence and severity as well as psychological strain. When treating patients with cluster headaches, accompanying psychological illnesses should carefully be taken into account.

Depression Among Patients with Chronic Cluster Headaches

Introduction: Chronic headaches account for a significant proportion of people leading a poor quality of life. Chronic cluster headaches can be defined as episodes of headache usually around the eye in the pattern of a cluster lasting 15-180 minutes each followed by multiple similar episodes occurring at a frequency of 1-8 times per day.

Method: This cross-sectional study was conducted in Jinnah Postgraduate Medical Center, Karachi. One hundred patients who were diagnosed cases of chronic cluster headaches were asked to fill the Beck Hopelessness Scale (BHS), Headache Impact Test (HIT), and Hospital Anxiety and Depression Scale (HADS).

Results: Of our study subjects, 57 were males and 43 were females. The mean HIT-6 score among these patients was found to be 60.5±7.67 (p-value = 0.04). The mean BHS score among these patients was found to be 13±6.87. The mean HADS reporting anxiety (HADS-A) was found to be 12.54 ± 5.65; whereas, the mean HADS reporting depression (HADS-D) was found to be 7.65 ± 4.65.

Conclusion: Patients with chronic cluster headaches have higher scores than the general population. There is an association between headache syndromes and depression which require further investigation.

The neuropsychology of cluster headache: cognition, mood, disability, and quality of life of patients with chronic and episodic cluster headache

BACKGROUND

Cluster headache (CH) is commonly regarded as one of the most disabling headache conditions, and referred to as one of the most painful conditions known to humankind. Although there has been some research indicating the severe impact of CH, there is little comprehensive evidence of its impact on quality of life, disability, mood, and cognitive function in both its episodic (ECH) and chronic (CCH) variants.

METHODS

This cross-sectional study investigates various aspects of cognitive function including intelligence, executive function, and memory, and mood, disability, and quality of life in 22 patients with ECH and CCH compared with age-matched healthy controls.

RESULTS

The results showed that intelligence and executive functions are intact in patients with CH, but that patients with CH perform significantly worse than healthy controls on tests of working memory and (all P < .05) report greater cognitive failures (P < .05). Around one third of both the ECH and CCH groups achieved "caseness" for depression, while self-reported anxiety was higher in those with CCH than the ECH patients, with 75% of the former compared with 38% of the latter groups achieving "caseness" on the measure of anxiety. Patients with CH reported high levels of disability, which was not significantly different between the 2 groups (P > .05). The patients with CH reported poor quality of life compared with healthy controls; however, this difference was not statistically significant.

CONCLUSION

Patients with CH show worse working memory, disturbance of mood, and poorer quality of life compared with healthy controls. The differences between patients with ECH and CCH, and the implications of these findings for the management of CH are discussed.

[Peripheral nerve stimulation in the treatment of various types of headache]

BACKGROUND AND OBJECTIVE

Headache has a great impact on patients' quality of life and in industrialized countries there is economic impact as well. One of the pathophysiologic theories to explain headache is activation of afferent C2-C3 nerve fibers. Afferent peripheral nerve stimulation by occipital nerve provocation at C2-C3 seems to alleviate headache by acting on the trigeminocervical complex, which would largely explain the effectiveness of this modality. The aim of this study was to describe peripheral nerve stimulation as an alternative therapy in patients who do not respond to other headache treatments.

MATERIAL AND METHODS

Multicenter retrospective study between April 2005 and May 2009, analyzing cases of patients treated with nerve stimulation for severe chronic headache. In all patients the medical history included type of headache, intensity of pain on a numerical scale, medical treatment used, and number of headache episodes. We recorded the percentage of patients with negative tests. Patients implanted with a generator assessed effectiveness on the numerical scale; we analyzed the percentage of perceived improvement at 1, 3, 6, and 12 months. We also analyzed the extent of coverage provided by the electrodes, patient satisfaction, reduction in the number of episodes and medication, and complications.

RESULTS

Of 31 patients, 87% had positive results, with a significant decrease in pain from baseline (P < .001); 85.2% reported sustained improvement of > 50%, and 96.3% reported a decrease of > 2 points on the pain scale. All patients expressed satisfaction during the period of follow-up. Fifty-six percent had no headaches after a year and 47% had stopped taking medication. The most frequent complication was electrode migration.

Trigeminal autonomic cephalalgias: a review and implications for dentistry

BACKGROUND

The authors review the epidemiology, clinical features, pathophysiology, diagnosis, treatment, orofacial presentations and dental implications of trigeminal autonomic cephalalgias (TACs): cluster headache (CH), paroxysmal hemicrania (PH) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT).

TYPES OF STUDIES REVIEWED

The authors conducted PUBMED searches for the period from 1968 through 2007 using the terms "trigeminal autonomic cephalalgias," "cluster headache," "paroxysmal hemicrania," "short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing," "epidemiology," "pathophysiology," "treatment," "oral," "facial" and "dentistry." They gave preference to articles reporting randomized, controlled trials and those published in English-language peer-reviewed journals.

RESULTS

TACs refers to a group of headaches characterized by unilateral head pain, facial pain or both with accompanying autonomic features. Although their pathophysiologies are unclear, CH, PH and SUNCT may be differentiated according to their clinical characteristics. Current treatments for each of the TACs are useful in alleviating the pain, with few refractory cases requiring surgical intervention. Patients with TACs often visit dental offices seeking relief for their pain.

CLINICAL IMPLICATIONS

Although the prevalence of TACs is small, it is important for dentists to recognize the disorder and refer patients to a neurologist. This will avoid the pitfall of administering unnecessary and inappropriate traditional dental treatments in an attempt to alleviate the neurovascular pain.

Trigeminal autonomic cephalalgias. Part 1: cluster headache

Cluster headache is characterized by severe, strictly unilateral pain attacks lasting 15 to 180 minutes localized to orbital, temporal, and midface areas accompanied by ipsilateral autonomic features. It represents 1 of 3 primary headaches classified as trigeminal autonomic cephalalgias. While its prevalence is small, it is not uncommon for cluster headache patients to present at dental offices seeking relief for their pain. It is important for oral health care providers to recognize cluster headache and render an accurate diagnosis. This will avoid the pitfall of implementing unnecessary and inappropriate traditional dental treatments in hopes of alleviating this neurovascular pain. The following article is part 1 of a review on trigeminal autonomic cephalalgias and focuses on cluster headache. Aspects of cluster headache including its prevalence and incidence, genetics, pathophysiology, clinical presentation, classification and variants, diagnosis, medical management, and dental considerations are discussed.

Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients

BACKGROUND

Cluster headache is a form of primary headache that features repeated attacks of excruciatingly severe headache usually occurring several times a day. Patients with chronic cluster headache have unremitting illness that necessitates daily preventive medical treatment for years. When medically intractable, the condition has previously been treatable only with cranially invasive or neurally destructive methods.

METHODS

Eight patients with medically intractable chronic cluster headache were implanted in the suboccipital region with electrodes for occipital nerve stimulation. Other than the first patient, who was initially stimulated unilaterally before being stimulated bilaterally, all patients were stimulated bilaterally during treatment.

FINDINGS

At a median follow-up of 20 months (range 6-27 months for bilateral stimulation), six of eight patients reported responses that were sufficiently meaningful for them to recommend the treatment to similarly affected patients with chronic cluster headache. Two patients noticed a substantial improvement (90% and 95%) in their attacks; three patients noticed a moderate improvement (40%, 60%, and 20-80%) and one reported mild improvement (25%). Improvements occurred in both frequency and severity of attacks. These changes took place over weeks or months, although attacks returned in days when the device malfunctioned (eg, with battery depletion). Adverse events of concern were lead migrations in one patient and battery depletion requiring replacement in four.

INTERPRETATION

Occipital nerve stimulation in cluster headache seems to offer a safe, effective treatment option that could begin a new era of neurostimulation therapy for primary headache syndromes.

Cluster headache treatment dilemmas: the experts respond

When conventional treatment approaches to cluster headache are unsuccessful, expert recommendations are relevant but may not be easily accessible to treating clinicians. We conducted a study of expert recommendations in response to standardized vignettes. Ten expert headache clinicians were asked what treatment they would recommend for a hypothetical 55-year-old male cluster headache patient in the following five situations: 1) known coronary artery disease with response only to sumatriptan; 2) strictly unilateral headaches unresponsive to preventive treatment; 3) effective abortive treatment not covered by insurance; 4) patient request to obtain methysergide from Canada; and 5) headaches responsive only to steroid treatment.

Serotonin receptor ligands: treatments of acute migraine and cluster headache

Fuelled by the development of the serotonin 5-HT(1B/1D) receptor agonists, the triptans, the last 15 years has seen an explosion of interest in the treatment of acute migraine and cluster headache. Sumatriptan was the first of these agonists, and it launched a wave of therapeutic advances. These medicines are effective and safe. Triptans were developed as cranial vasoconstrictors to mimic the desirable effects of serotonin, while avoiding its side-effects. It has subsequently been shown that the triptans' major action is neuronal, with both peripheral and central trigeminal inhibitory effects, as well as actions in the thalamus and at central modulatory sites, such as the periaqueductal grey matter. Further refinements may be possible as the 5-HT(1D) and 5-HT(1F) receptor agonists are explored. Serotonin receptor pharmacology has contributed much to the better management of patients with primary headache disorders.