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Membrilla JA, Cuadrado ML, González-García N, Porta-Etessam J, Sánchez-Soblechero A, Lozano Ros A, Gonzalez-Martinez A, Gago-Veiga AB, Quintas S, Rodríguez Vico JS, Jaimes A, Llorente Ayuso L, Roa J, Estebas C, Díaz-de-Terán J. The profile of refractory chronic cluster headache. Neurol Sci 2024:10.1007/s10072-024-07708-0. [PMID: 39044103 DOI: 10.1007/s10072-024-07708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Chronic cluster headache (CCH) is a relatively rare primary headache disorder whose management is often challenging. The prevalence of refractory CCH (rCCH) is unknown. Our aim is to describe the frequency of rCCH within a population of CCH, define the clinical profile of the refractory patients and the treatments they underwent. METHODS We conducted a cross-sectional study through a review of the medical records of CCH patients in six hospitals in Madrid, Spain. Data on epidemiological, clinical presentation, treatment and disease activity at the moment were collected. The European Headache Federation diagnostic criteria were used for rCCH definition. High disease activity was defined as having at least 3 severe attacks per week that impact quality of life despite treatment. Non-rCCH and rCCH groups were compared. RESULTS 88 CCH patients were analyzed, 68.2% (60/88) met rCCH criteria at some point in their evolution. A longer diagnostic delay (4.6 ± 7.1 vs. 3.2 ± 3.7 years, p = 0.017) was observed in rCCH. All rCCH patients tried therapies without established evidence from randomized clinical trials. OnabotulinumtoxinA and galcanezumab were initiated in 77.3% (68/88) and 5.7% (5/88), but discontinued in 52.9% (36/68) and 60.0% (3/5), respectively. Occipital nerve stimulation (ONS) was implanted in 29.6% (26/88), with 50.0% (13/26) still active. Other treatment options are described and discussed. Despite treatment, 60.2% (53/88) still have high disease activity. CONCLUSION CCH is a disorder with poor prognosis, meeting refractoriness criteria in more than half. OnabotulinumtoxinA and ONS could be the effective in refractory patients.
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Affiliation(s)
- Javier A Membrilla
- Neurology Department, Hospital Universitari Francesc de Borja, Avinguda de la Medicina, 6, Gandia, 46702, València, Spain.
| | - María-Luz Cuadrado
- Neurology Department, Hospital Clínico San Carlos, Madrid, Spain
- Medicine Department, Universidad Complutense, Madrid, Spain
| | | | - Jesús Porta-Etessam
- Neurology Department, Hospital Clínico San Carlos, Madrid, Spain
- Medicine Department, Universidad Complutense, Madrid, Spain
| | | | - Alberto Lozano Ros
- Neurology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Sonia Quintas
- Neurology Department, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Alex Jaimes
- Neurology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | | | - Javier Roa
- Neurology Department, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Carlos Estebas
- Neurology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Javier Díaz-de-Terán
- Neurology Department, Hospital Universitario La Paz, Madrid, Spain
- Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital, Universidad Autónoma de Madrid - Getafe Universitary Hospital - Universidad Europea de Madrid), Madrid, Spain
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Petersen AS, Kristensen DM, Westgate CSJ, Folkmann-Hansen T, Lund N, Barloese M, Søborg MLK, Snoer A, Johannsen TH, Frederiksen H, Juul A, Jensen RH. Compensated Hypogonadism Identified in Males with Cluster Headache: A Prospective Case-Controlled Study. Ann Neurol 2024; 95:1149-1161. [PMID: 38558306 DOI: 10.1002/ana.26906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/22/2024] [Accepted: 02/13/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Androgens have been hypothesized to be involved in the pathophysiology of cluster headache due to the male predominance, but whether androgens are altered in patients with cluster headache remains unclear. METHODS We performed a prospective, case-controlled study in adult males with cluster headache. Sera were measured for hormones including testosterone, luteinizing hormone (LH), and sex hormone-binding globulin in 60 participants with episodic cluster headache (during a bout and in remission), 60 participants with chronic cluster headache, and 60 age- and sex-matched healthy controls. Free testosterone (fT) was calculated according to the Vermeulen equation. Shared genetic risk variants were assessed between cluster headache and testosterone concentrations. RESULTS The mean fT/LH ratio was reduced by 35% (95% confidence interval [CI]: 21%-47%, p < 0.0001) in patients with chronic cluster headache and by 24% (95% CI: 9%-37%, p = 0.004) in patients with episodic cluster headache compared to controls after adjusting for age, sleep duration, and use of acute medication. Androgen concentrations did not differ between bouts and remissions. Furthermore, a shared genetic risk allele, rs112572874 (located in the intron of the microtubule associated protein tau (MAPT) gene on chromosome 17), between fT and cluster headache was identified. INTERPRETATION Our results demonstrate that the male endocrine system is altered in patients with cluster headache to a state of compensated hypogonadism, and this is not an epiphenomenon associated with sleep or the use of acute medication. Together with the identified shared genetic risk allele, this may suggest a pathophysiological link between cluster headache and fT. ANN NEUROL 2024;95:1149-1161.
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Affiliation(s)
- Anja S Petersen
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - David M Kristensen
- Department of Growth and Reproduction, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
- Department of Science and Environment, Roskilde University, Denmark
| | - Connar S J Westgate
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - Thomas Folkmann-Hansen
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Glostrup, Denmark
- Novo Nordisk Foundation Center for Protein Research, Copenhagen University, Copenhagen, Denmark
| | - Nunu Lund
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - Mads Barloese
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional and Diagnostic Imaging and Research, University of Copenhagen, Hvidovre Hospital, Hvidovre, Denmark
| | - Marie-Louise K Søborg
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - Agneta Snoer
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Glostrup, Denmark
| | - Trine H Johannsen
- Department of Growth and Reproduction, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Growth and Reproduction, International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Frederiksen
- Department of Growth and Reproduction, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Growth and Reproduction, International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anders Juul
- Department of Growth and Reproduction, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Growth and Reproduction, International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, University of Copenhagen, Rigshospitalet-Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Ciciarelli MC, Simioni CVDMG, Londero RG. Headaches in adults in supplementary health: management. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e023D701. [PMID: 38511747 PMCID: PMC10941913 DOI: 10.1590/1806-9282.023d701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 03/22/2024]
Affiliation(s)
| | | | - Renata Gomes Londero
- Brazilian Academy of Neurology, Porto Alegre Clinical Hospital – Porto Alegre (RS), Brazil
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May A, Evers S, Goadsby PJ, Leone M, Manzoni GC, Pascual J, Carvalho V, Romoli M, Aleksovska K, Pozo-Rosich P, Jensen RH. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol 2023; 30:2955-2979. [PMID: 37515405 DOI: 10.1111/ene.15956] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND AND PURPOSE Cluster headache is a relatively rare, disabling primary headache disorder with a major impact on patients' quality of life. This work presents evidence-based recommendations for the treatment of cluster headache derived from a systematic review of the literature and consensus among a panel of experts. METHODS The databases PubMed (Medline), Science Citation Index, and Cochrane Library were screened for studies on the efficacy of interventions (last access July 2022). The findings in these studies were evaluated according to the recommendations of the European Academy of Neurology, and the level of evidence was established using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). RECOMMENDATIONS For the acute treatment of cluster headache attacks, there is a strong recommendation for oxygen (100%) with a flow of at least 12 L/min over 15 min and 6 mg subcutaneous sumatriptan. Prophylaxis of cluster headache attacks with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy and tolerability) is recommended. Corticosteroids are efficacious in cluster headache. To reach an effect, the use of at least 100 mg prednisone (or equivalent corticosteroid) given orally or at up to 500 mg iv per day over 5 days is recommended. Lithium, topiramate, and galcanezumab (only for episodic cluster headache) are recommended as alternative treatments. Noninvasive vagus nerve stimulation is efficacious in episodic but not chronic cluster headache. Greater occipital nerve block is recommended, but electrical stimulation of the greater occipital nerve is not recommended due to the side effect profile.
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Affiliation(s)
- Arne May
- Department of Systems Neuroscience, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
| | - Stefan Evers
- Department of Neurology, Lindenbrunn Hospital, Coppenbrügge, Germany
- Faculty of Medicine, University of Münster, Münster, Germany
| | - Peter J Goadsby
- NIHR King's CRF, SLaM Biomedical Research Centre, King's College London, London, UK
| | - Massimo Leone
- Neuroalgology Department, Foundation of the Carlo Besta Neurological Institute, IRCCS, Milan, Italy
| | | | - Julio Pascual
- Service of Neurology, University Hospital Marqués de Valdecilla, Universidad de Cantabria and IDIVAL, Santander, Spain
| | - Vanessa Carvalho
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Bufalini Hospital, Cesena, Italy
| | | | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Headache Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Rigmor H Jensen
- Danish Headache Center, Department of Neurology, Rigshospitalet-Glostrup, University of Copenhagen, Copenhagen, Denmark
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Membrilla JA, Roa J, Díaz-de-Terán J. Preventive treatment of refractory chronic cluster headache: systematic review and meta-analysis. J Neurol 2023; 270:689-710. [PMID: 36310189 DOI: 10.1007/s00415-022-11436-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preventive treatment for refractory chronic cluster headache (rCCH) is challenging and many therapies have been tried. OBJECTIVE To study what could be considered the therapy of choice in rCCH through a systematic review and meta-analysis. METHODS This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered in PROSPERO (ID CRD42021290983). A systematic search was performed in MEDLINE, Embase, Cochrane, clinicaltrials.gov, and the WHO's-International-Clinical-Trials-Registry-Platform. Studies on the preventive treatment for rCCH as defined by the European Headache Federation consensus statement were included. A meta-analysis of the pooled response rate was conducted for the different therapies. RESULTS Of 336 results, 45 were eligible for inclusion. Most articles studied the effect of neuromodulation as a preventive treatment for rCCH. The most studied neuromodulation technique was occipital nerve stimulation (ONS), with a pooled response rate in the meta-analysis of 57.3% (95% CI 0.481-0.665). Deep brain stimulation (DBS) was the second most studied treatment with a pooled response rate of 77.0% (95% CI 0.594-0.957). DBS results were more heterogeneous than ONS, which could be related to the different stimulation targets in DBS studies, and reported more serious adverse events than in ONS studies. The remaining therapies (anti-CGRP pathway drugs, warfarin, ketamine-magnesium infusions, serial occipital nerve blocks, clomiphene, onabotulinum toxin A, ketogenic diet, sphenopalatine ganglion radiofrequency or stimulation, vagus nerve stimulation, percutaneous bioelectric current stimulation, upper cervical cord stimulation, and vidian neurectomy) present weaker results or have less quality of evidence. CONCLUSIONS The results of this systematic review and meta-analysis suggest that ONS could be the first therapeutic strategy for patients with rCCH based on the current evidence.
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Affiliation(s)
- Javier A Membrilla
- Neurology Department, "La Paz" University Hospital, P.º de la Castellana 261, 28046, Madrid, Spain.
| | - Javier Roa
- Neurology Department, "La Paz" University Hospital, P.º de la Castellana 261, 28046, Madrid, Spain
| | - Javier Díaz-de-Terán
- Neurology Department, "La Paz" University Hospital, P.º de la Castellana 261, 28046, Madrid, Spain
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Sax JL, Hershman SN, Hubler Z, Allimuthu D, Elitt MS, Bederman I, Adams DJ. Enhancers of Human and Rodent Oligodendrocyte Formation Predominantly Induce Cholesterol Precursor Accumulation. ACS Chem Biol 2022; 17:2188-2200. [PMID: 35833657 PMCID: PMC9773236 DOI: 10.1021/acschembio.2c00330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Regeneration of myelin in the central nervous system is being pursued as a potential therapeutic approach for multiple sclerosis. Several labs have reported small molecules that promote oligodendrocyte formation and remyelination in vivo. Recently, we reported that many such molecules function by inhibiting a narrow window of enzymes in the cholesterol biosynthesis pathway. Here we describe a new high-throughput screen of 1,836 bioactive molecules and a thorough re-analysis of more than 60 molecules previously identified as promoting oligodendrocyte formation from human, rat, or mouse oligodendrocyte progenitor cells. These studies highlight that an overwhelming fraction of validated screening hits, including several molecules being evaluated clinically for remyelination, inhibit cholesterol pathway enzymes like emopamil-binding protein (EBP). To rationalize these findings, we suggest a model that relies on the high druggability of sterol-metabolizing enzymes and the ability of cationic amphiphiles to mimic the transition state of EBP. These studies further establish cholesterol pathway inhibition as a dominant mechanism among screening hits that enhance human, rat, or mouse oligodendrocyte formation.
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Affiliation(s)
- Joel L Sax
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Samantha N Hershman
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Zita Hubler
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Dharmaraja Allimuthu
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Matthew S Elitt
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Ilya Bederman
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
| | - Drew J Adams
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106, United States
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Prasad S, Mehadi A, Kaka N, Jhaveri S, Avanthika C, Patel N, Augustine I, Issani A. Diagnostic protocols and newer treatment modalities for cluster headache. Dis Mon 2022; 68:101316. [PMID: 35000758 DOI: 10.1016/j.disamonth.2021.101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cluster Headaches are one of the most arguably severe forms of primary headache syndrome that affects humans. Although it is relatively uncommon, it has a significant impact on the quality of life. It is a multifactorial disease that has risk factors ranging from seasonal changes, lifestyle habits to genetics. It occurs in 2 forms- Episodic and Chronic, each having its well-defined Diagnostic Criteria. Moreover, Cluster Headache has an exhaustive list of options for both Preventive and Abortive treatment. This article focuses on Cluster Headache, its pathophysiology, risk factors, differentials, and its diverse treatment modalities. In this study, an all-language literature search was conducted on Medline, Cochrane, Embase, and Google Scholar till October 2021. The following search strings and Medical Subject Headings (MeSH) terms were used: "Cluster Headache," "Triptans," "Neuromodulation," and "Migraine." We explored the literature on Cluster Headache for its epidemiology, pathophysiology, the role of various genes and how they bring about the disease as well as its episodic and chronic variants, and treatment options. Although we have a wide variety of options for Preventive and Abortive therapy, newer more effective pharmacological and non-pharmacological interventions are being developed, and must be integrated into new treatment protocols.
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Affiliation(s)
- Sakshi Prasad
- Faculty of Medicine, National Pirogov, Memorial Medical University, 21018, Vinnytsya, Ukraine.
| | | | - Nirja Kaka
- GMERS Medical College, Himmatnagar 383001, Gujarat, India.
| | - Sharan Jhaveri
- Smt. NHL Municipal Medical college, Ahmedabad 380006, India.
| | - Chaithanya Avanthika
- Karnataka Institute of Medical Sciences,PB Road, Hubli 580022, Karnataka, India.
| | - Neil Patel
- GMERS Medical College, Himmatnagar 383001, Gujarat, India.
| | - Ivan Augustine
- Government Medical college Thrissur 680596, Kerala,India.
| | - Ali Issani
- Baqai Medical University, Karachi, Pakistan.
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Chronic Cluster Headache Update and East-West Comparisons: Focusing on Clinical Features, Pathophysiology, and Management. Curr Pain Headache Rep 2020; 24:68. [PMID: 32990832 DOI: 10.1007/s11916-020-00902-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW This review provides an update on chronic cluster headache (CH) focusing on clinical features, pathophysiology, and management as well as comparisons between Eastern and Western populations. RECENT FINDINGS Chronic CH in Eastern populations was relatively rare, compared to that in Western populations. Lacrimation and/or conjunctival injection is the most frequently reported cranial autonomic symptom, and visual aura is predominant in chronic CH patients. Neuroimaging evidence in both ethnic groups suggests that CH pathophysiology involves the hypothalamus and pain-modulatory areas, with dynamic alternations between CH episodes. Recent evidence indicates that midbrain dopaminergic systems may participate in CH chronicity. Noteworthy advances have emerged in neuromodulatory therapies for chronic CH, but treatment with calcitonin gene-related peptide (CGRP) monoclonal antibodies has been unsuccessful. Recent evidence shows divergence of chronic CH between Eastern and Western populations. Neuromodulatory therapies but not CGRP inhibition is effective in this intractable patient group.
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Rozen TD. Can the effects of the mitochondrial DNA mutations found in Leber’s hereditary optic neuropathy be protective against the development of cluster headache in smokers? CEPHALALGIA REPORTS 2020. [DOI: 10.1177/2515816320939571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Is it possible that some mitochondrial DNA (mtDNA) mutations enhance the risk of developing a headache disorder while other mutations actually confer a protective effect? Mitochondrial disorders have been linked to migraine but very rarely to cluster headache (CH). The true pathogenesis of CH is unknown but a linkage to cigarette smoking is irrefutable. Leber’s hereditary optic neuropathy is a syndrome of bilateral vision loss that typically manifests in a patient’s 20s and 30s, is male predominant, and its sufferers are heavy smokers and heavy drinkers. Tobacco exposure is so linked to the condition that only smokers appear to develop vision loss while nonsmokers remain unaffected carriers of their mutations. In essence, the Leber’s hereditary optic neuropathy population is the CH population but at present there have been no reported cases of CH in this mitochondrial subgroup. Thus, could the effects of the mtDNA mutations found in Leber’s hereditary optic neuropathy, which involve complex I of the electron transport chain, actually confer a protective effect against the development of CH? This article will delve into this theory.
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Affiliation(s)
- Todd D Rozen
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, USA
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Abstract
Cluster headache is characterised by attacks of excruciating unilateral headache or facial pain lasting 15 min to 3 h and is seen as one of the most intense forms of pain. Cluster headache attacks are accompanied by ipsilateral autonomic symptoms such as ptosis, miosis, redness or flushing of the face, nasal congestion, rhinorrhoea, peri-orbital swelling and/or restlessness or agitation. Cluster headache treatment entails fast-acting abortive treatment, transitional treatment and preventive treatment. The primary goal of prophylactic and transitional treatment is to achieve attack freedom, although this is not always possible. Subcutaneous sumatriptan and high-flow oxygen are the most proven abortive treatments for cluster headache attacks, but other treatment options such as intranasal triptans may be effective. Verapamil and lithium are the preventive drugs of first choice and the most widely used in first-line preventive treatment. Given its possible cardiac side effects, electrocardiogram (ECG) is recommended before treating with verapamil. Liver and kidney functioning should be evaluated before and during treatment with lithium. If verapamil and lithium are ineffective, contraindicated or discontinued because of side effects, the second choice is topiramate. If all these drugs fail, other options with lower levels of evidence are available (e.g. melatonin, clomiphene, dihydroergotamine, pizotifen). However, since the evidence level is low, we also recommend considering one of several neuromodulatory options in patients with refractory chronic cluster headache. A new addition to the preventive treatment options in episodic cluster headache is galcanezumab, although the long-term effects remain unknown. Since effective preventive treatment can take several weeks to titrate, transitional treatment can be of great importance in the treatment of cluster headache. At present, greater occipital nerve injection is the most proven transitional treatment. Other options are high-dose prednisone or frovatriptan.
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Abstract
PURPOSE OF REVIEW Cluster headache stands among the worst debilitating pain conditions. Available treatments for cluster headache have often disabling side effects, are not tolerated, or are ineffective. The management of drug-refractory chronic forms is challenging. New treatments are warranted and reported here. RECENT FINDINGS In cluster headache acute treatment, delivery systems like Demand Valve Oxygen or nonrebreather-type masks could enhance the effectiveness of inhaled oxygen therapy. Noninvasive vagus nerve stimulation relieves cluster headache pain at short-term in episodic patients. Sphenopalatine ganglion stimulation combines acute and preventive properties in subsets of patients and is of interest in selected refractory chronic forms. In cluster headache prevention, 'hypothalamic' deep brain stimulation is being refined using slightly different stereotactic coordinates or lower risk methods like endoventricular stimulation. Anti-CGRP monoclonal antibodies provide interesting results in episodic cluster headache, have a good safety profile, but do not appear effective in chronic cluster headache. SUMMARY These novel approaches provide additional alternatives to conventional cluster headache management, but results obtained in chronic forms are often disappointing. Research on cluster headache is often hampered by the lack of awareness in the medical world and by the relatively low prevalence of cluster headache compared with migraine. However, common features shared by these two primary headaches could help developing disease-specific therapies.
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Delaruelle Z, Ivanova TA, Khan S, Negro A, Ornello R, Raffaelli B, Terrin A, Mitsikostas DD, Reuter U. Male and female sex hormones in primary headaches. J Headache Pain 2018; 19:117. [PMID: 30497379 PMCID: PMC6755575 DOI: 10.1186/s10194-018-0922-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/20/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The three primary headaches, tension-type headache, migraine and cluster headache, occur in both genders, but all seem to have a sex-specific prevalence. These gender differences suggest that both male and female sex hormones could have an influence on the course of primary headaches. This review aims to summarise the most relevant and recent literature on this topic. METHODS Two independent reviewers searched PUBMED in a systematic manner. Search strings were composed using the terms LH, FSH, progesteron*, estrogen*, DHEA*, prolactin, testosterone, androgen*, headach*, migrain*, "tension type" or cluster. A timeframe was set limiting the search to articles published in the last 20 years, after January 1st 1997. RESULTS Migraine tends to follow a classic temporal pattern throughout a woman's life corresponding to the fluctuation of estrogen in the different reproductive stages. The estrogen withdrawal hypothesis forms the basis for most of the assumptions made on this behalf. The role of other hormones as well as the importance of sex hormones in other primary headaches is far less studied. CONCLUSION The available literature mainly covers the role of sex hormones in migraine in women. Detailed studies especially in the elderly of both sexes and in cluster headache and tension-type headache are warranted to fully elucidate the role of these hormones in all primary headaches.
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Affiliation(s)
- Zoë Delaruelle
- Department of Neurology, University Hospital Ghent, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | | | - Sabrina Khan
- Danish Headache Center, Glostrup Hospital, Copenhagen, Denmark
| | - Andrea Negro
- Dipartimento di Medicina Clinica e Molecolare, Universita degli Studi di Roma La Sapienza, Rome, Italy
| | - Raffaele Ornello
- Department of Neurology, University of La’Aquila, L’Aquila, Italy
| | - Bianca Raffaelli
- Departmentt of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Alberto Terrin
- Department of Neurosciences, Headache Center, University of Padua, Padua, Italy
| | - Dimos D. Mitsikostas
- Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Uwe Reuter
- Charite Universitatsmedizin Berlin, Berlin, Germany
| | - on behalf of the European Headache Federation School of Advanced Studies (EHF-SAS)
- Department of Neurology, University Hospital Ghent, Corneel Heymanslaan 10, 9000 Ghent, Belgium
- First Moscow State Medical University, Moscow, Russia
- Danish Headache Center, Glostrup Hospital, Copenhagen, Denmark
- Dipartimento di Medicina Clinica e Molecolare, Universita degli Studi di Roma La Sapienza, Rome, Italy
- Department of Neurology, University of La’Aquila, L’Aquila, Italy
- Departmentt of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurosciences, Headache Center, University of Padua, Padua, Italy
- Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Charite Universitatsmedizin Berlin, Berlin, Germany
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Rozen TD. Linking Cigarette Smoking/Tobacco Exposure and Cluster Headache: A Pathogenesis Theory. Headache 2018; 58:1096-1112. [PMID: 30011061 DOI: 10.1111/head.13338] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION To propose a hypothesis theory to establish a linkage between cigarette smoking and cluster headache pathogenesis. BACKGROUND Cluster headache is a primary headache syndrome grouped under the trigeminal autonomic cephalalgias. What distinguishes cluster headache from all other primary headache conditions is its inherent connection to cigarette smoking. It is undeniable that tobacco exposure is in some manner related to cluster headache. The connection to tobacco exposure for cluster headache is so strong that even if an individual sufferer never smoked, then that individual typically had significant secondary smoke exposure as a child from parental smoking behavior and in many instances both scenarios exist. The manner by which cigarette smoking is connected to cluster headache pathogenesis is unknown at present. If this could be determined this may contribute to advancing our understanding of cluster headache pathophysiology. METHODS/RESULTS Hypothesis statement. CONCLUSION The hypothesis theory will include several principles: (1) the need of double lifetime tobacco exposure, (2) that cadmium is possibly the primary agent in cigarette smoke that leads to hypothalamic-pituitary-gonadal axis toxicity promoting cluster headache, (3) that the estrogenization of the brain and its specific sexually dimorphic nuclei is necessary to develop cluster headache with tobacco exposure, and (4) that the chronic effects of smoking and its toxic metabolites including cadmium and nicotine on the cortex are contributing to the morphometric and orexin alterations that have been previously attributed to the primary headache disorder itself.
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