Treatment of Cluster Headache

Cluster Headache Presenting As Sinonasal Pathology in a Young Adult: A Diagnostic Odyssey

Cluster headache is a debilitating primary headache disorder marked by severe, unilateral pain often accompanied by autonomic symptoms. We describe the case of a 20-year-old student who presented with excruciating peri-orbital pain localized to the right side, accompanied by ipsilateral nasal obstruction, a nasal spur, and a deviated nasal septum (DNS). The initial clinical picture strongly suggested sinonasal pathology, leading to investigations and treatments aimed at this presumed diagnosis. However, as the patient's symptoms persisted and evolved over time, with episodes of recurrent and intense pain associated with ipsilateral tearing, rhinorrhea, and ptosis, further evaluation was pursued. A comprehensive assessment, including detailed headache characteristics, neurological examination, and neuroimaging, ultimately revealed the diagnosis of cluster headache. This case emphasizes the diagnostic challenges associated with atypical presentations of cluster headaches, the importance of a meticulous clinical evaluation, and the need for early recognition to provide timely and effective interventions for these severely affected individuals.

Regional cerebral blood flow as predictor of response to occipital nerve block in cluster headache

Background

Cluster headache is an excruciating disorder with no cure. Greater occipital nerve blockades can transiently suppress attacks in approximately 50% of patients, however, its mechanism of action remains uncertain, and there are no reliable predictors of treatment response. To address this, we investigated the effect of occipital nerve blockade on regional cerebral blood flow (rCBF), an index of brain activity, and differences between treatment responders and non-responders. Finally, we compared baseline perfusion maps from patients to a matched group of healthy controls.

Methods

21 male, treatment-naive patients were recruited while in a cluster headache bout. During a pain-free phase between headaches, patients underwent pseudo-continuous arterial spin labelled MRI assessments to provide quantitative indices of rCBF. MRIs were performed prior to and 7-to-21 days following treatment. Patients also recorded the frequency of their headache attacks in a daily paper diary. Neuropsychological assessment including anxiety, depression and quality of life measures was performed in a first, scanning free session for each patient.

Results

Following treatment, patients demonstrated relative rCBF reductions in posterior temporal gyrus, cerebellum and caudate, and rCBF increases in occipital cortex. Responders demonstrated relative rCBF increases, compared to non-responders, in medial prefrontal cortex and lateral occipital cortex at baseline, but relative reductions in cingulate and middle temporal cortices. rCBF was increased in patients compared to healthy controls in cerebellum and hippocampus, but reduced in orbitofrontal cortex, insula and middle temporal gyrus.

Conclusions

We provide new mechanistic insights regarding the aetiology of cluster headache, the mechanisms of action of occipital nerve blockades and potential predictors of treatment response. Future investigation should determine whether observed effects are reproducible and extend to other headache disorders.

Gene polymorphism association studies in cluster headache: A field synopsis and systematic meta-analyses

BACKGROUND

A plethora of studies have attempted to identify genetic determinants of disease susceptibility and treatment response of patients with cluster headache (CH), but results are often conflicting, and no comprehensive overview with a quantitative summary of the evidence in this field is available.

METHODS

A systematic search of relevant publications was performed without any language restrictions on PubMed, Web of Knowledge, Cochrane Library, and OpenGrey, up to December 2020. A standardized data extraction form was used to collect relevant data from each included study. Meta-analyses were conducted for gene polymorphisms investigated in at least two studies and the Bayesian false discovery probability (BFDP) test was applied to the pooled odds ratios (ORs) to assess the credibility of the observed associations.

RESULTS

Among the 27 articles identified by the systematic review, 17 studies evaluating 12 single nucleotide polymorphisms (SNPs) were included in the quantitative data analysis. The pooled results showed no significant association with CH risk of 10 SNPs, including five SNPs of HCRTR2 (rs2653349, rs2653342, rs3122156, rs10498801, and rs3800539), two SNPs of ADH4 (rs1800759 and rs1126671), CLOCK rs1801260, and two SNPs (rs1006417 and ADCYAP1R1 rs12668955) previously identified by a genome-wide association study (GWAS). Conversely, the pooled results revealed the association of the HCRTR2 rs9357855 A allele with a higher risk of CH (A vs. G, OR: 1.33, 95% CI: 1.04-1.72, p = 0.026), and of GNB3 rs5443 with a higher response rate of patients with CH to triptan drugs (CT+TT vs. CC, OR: 1.96, 95% CI: 1.04-3.72, p = 0.038). However, assuming a prior probability of 0.001, the respective BFDP values being higher than 0.8 (BFDP_rs9357855  = 0.998; BFDP_rs5443  = 0.998) revealed lack of noteworthy results.

CONCLUSIONS

Well-designed GWASs and large replication studies are still needed to identify reliable genetic variants of disease susceptibility and treatment response of patients with CH.

Cluster Headache: A Review and Update in Treatment

PURPOSE OF REVIEW

The treatment of cluster headache has evolved to include a handheld neuromodulation device and a monoclonal antibody in addition to more traditional agents.

RECENT FINDINGS

Galcanezumab is an approved treatment for episodic cluster headache. The non-invasive vagal nerve stimulator has been shown to be effective as a treatment for episodic cluster headache. Dedicated pituitary imaging may not be necessary with a normal MRI of the brain. Cluster headache is the most common trigeminal-autonomic cephalalgia, characterized by unilateral, frequent, debilitating attacks associated with ipsilateral autonomic symptoms. Attacks have a circadian and, often, seasonal pattern with periods of remission that can last months to years in episodic patients. Though a rare disease, an increasing number of studies have revealed novel targets for treatment. Treatment in cluster headache should focus on early intervention to reduce frequency of attacks and the length of the cycle, which improves outcomes and disability. Acute therapy is used to treat attacks, while bridging and preventive therapies are combined to reduce cycle length. Case 1: A 43-year-old man presents with the chief complaint of severe headaches. Upon general examination, he seems uncomfortable, agitated, and exhausted. He states that he hasn't "slept in over a week because of debilitating headaches." His headaches start around the same time every night: when he lays down to go to sleep. The pain is described as sharp, like a "hot poker" to his left eye. His partner has noticed that his eye droops and turns red when the pain starts. The attacks come on abruptly and prevent him from sleeping. The severe pain lasts 30 to 45 min, but he has mild-to-moderate pain that lingers for the rest of the night. He has seen his primary care physician, an allergist, and an ear, nose, and throat (ENT) specialist before coming to see a neurologist. Similar headaches occurred last year during the month of October as well. On further questioning, he reports that these headache attacks have been occurring almost yearly for the past 7 years. Each year, these headaches come on as the weather is changing and occur on a nightly basis for about 3 to 4 weeks.

Can Psychedelics Alleviate Symptoms of Cluster Headache and Accompanying Mental Health Problems? A Case Report Involving Hawaiian Baby Woodrose

Preliminary evidence supports the efficacy of psychedelics in the alleviation of cluster headache and mental health problems. We describe a case of an individual with cluster headache and mood disorder who claims to have benefited from her use of psychedelics. A forty-eight-year-old woman was referred to a private Australian mental health clinic for the management of chronic pain and depression. She reported using Hawaiian baby woodrose to successfully alleviate symptoms of cluster headache and the accompanying mental health problems. Incidental observation also highlighted the potential therapeutic benefits of antiviral therapy. This is the first case report to concurrently examine the analgesic and psycho-spiritual effects of Hawaiian baby woodrose, with results in support of nascent research in this field. The results of this case report highlight the need for further research into the use of psychedelics in the management of cluster headache and mental illness.

Emerging Novel Pharmacological Non-opioid Therapies in Headache Management: a Comprehensive Review

PURPOSE OF REVIEW

Chronic headache is a significant worldwide problem despite advances in treatment options. Chronic headaches can have significant a detrimental impact on the activities of daily living.

RECENT FINDINGS

Patients who do not obtain relief from chronic head and neck pain from conservative treatments are commonly being managed with interventional treatments. These interventional treatment options include botulinum toxin A, injections, local occipital nerve anesthetic and corticosteroid infiltration, occipital nerve subcutaneous stimulation and occipital nerve pulsed radiofrequency (PRF), sphenopalatine ganglion block, and radiofrequency techniques. Recently, evidence has emerged to support non-opioid-based drug and interventional approaches. Overall, more research is necessary to clarify the safety and efficacy of interventional treatments and to better understand the pathogenesis of chronic headache pain.

The Basic Four Approach to Clinical Neuroscience Instruction: Using Cognitive Load Theory to Enhance Case-based Learning

Among medical students, neurosceince is considered a notoriously difficult subject. This challenges faculty to teach preclinical neurology in more engaging, efficient, and prioritized ways. Traditional approaches to neuroscience instruction typically begin with neuroanatomy and advance to clinical problem solving after this foundation of knowledge is in place. Over the past 45 years, neurology faculty at Mayo Clinic Alix School of Medicine have developed and iteratively refined an inverted approach called The Basic Four. The Basic Four uses authentic clinical scenarios as the basis for neuroscience instruction and incorporates principles from cognitive load theory to calibrate load on students' working memory. This perspective describes The Basic Four and illustrates how cognitive load theory can be used to enhance case-based learning.