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Cluster Headache

Cluster Headache. 3 rd BIENNIAL HULL-BASH NATIONAL MEETING ON HEADACHE Anish Bahra The National Hospital for Neurology and Neurosurgery Whipps Cross University Hospital. Lifetime prevalence Tension-type headache ~ 60-80% Migraine headache 15% Cluster Headache 0.1%.

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Cluster Headache

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  1. Cluster Headache 3rd BIENNIAL HULL-BASH NATIONAL MEETING ON HEADACHE Anish Bahra The National Hospital for Neurology and Neurosurgery Whipps Cross University Hospital

  2. Lifetime prevalence Tension-type headache ~ 60-80% Migraine headache 15% Cluster Headache 0.1%

  3. Severe unilateral orbital, supraorbital and/or temporal pain Associated symptoms: Conjunctival injection / Lacrimation Nasal congestion / Rhinorrhea Eyelid oedema Forehead and facial sweating Ptosis and Miosis A sense of restlessness / agitation 15-180 minutes duration 1 / alternate days – 8 /day IHS Classification for Cluster Headache (2004)

  4. Cluster Headache – Defining features Strictly unilateral V1 pain + Autonomic features Restlessness / agitation Short-duration / daily / bouts

  5. Cluster Headache – Laterality %

  6. Cluster Headache – Laterality %

  7. % Retro-orbital 92 Temporal 70 Upper teeth 50 Forehead 46 Jaw 45 Cheek 45 % Lower teeth 32 Neck 31 Nose 20 Ear 17 Shoulder 13 Vertex 7 Occiput 6 Parietal 1 Site of pain →V1 Bahra A et al. Neurology 2002; 58: 354-361

  8. Jaw V3 Cheek V2 Lower teeth V3 Neck C2/3 Nose V2 Ear C2 Shoulder C3/4 Vertex C2 Occiput C2 Parietal C2 Retro-orbital V1 Temporal V1 Upper teeth V2 Forehead V1

  9. Autonomic Features %

  10. Autonomic Features % CH – 98%1 Migraine – 25%2 1. Torelli, 2001 n=553 2. Obermann, 2007 n=841

  11. Attack Duration and Frequency N CH Migraine Duration 15-180 mins 4-72hrs Frequency 1 / day 1-2 / month

  12. Additional Features % CH Migraine

  13. Episodic Cluster Headache → 90% 7 days - One year Pain-free interval ≥ one month Chronic Cluster Headache → 10% ≥ one year without remission ≥ one year with remissions  one month IHS Classification Criteria for Cluster Headache

  14. Cluster Headache Attack Provocation • 1mg s/l nitroglycerine provocation • During (n=28) and out (n=15) of active bout • Attack precipitated in ALL during active bout • No attack precipitated out of the bout • Ekbom, K. Arch Neurol 1968; 19: 487

  15. Cluster Headache & Imaging • All patients ?

  16. Symptomatic Cluster Headache • Aneurysm of the ACA • Pituitary tumour • AVM of the occipital lobe • Vertebral artery aneurysm • Meningioma of the cervical canal (C2)

  17. Symptomatic Cluster Headache • Aneurysm of the ACA • Pituitary tumour • AVM of the occipital lobe • Vertebral artery aneurysm • Meningioma of the cervical canal (C2)

  18. Symptomatic Cluster Headache • Typical or atypical • Response to treatment ≡ Primary CH • ± Resolution with Rx of precipitating pathology

  19. Symptomatic Cluster Headache • Phenotype • Rx Response Cannot differentiate b/u Primary & Secondary CH

  20. Locker at al. Headache. 2006 ( n = 558) / Ramirez-Lassepas. Arch Neurol. 1997

  21. Cluster Headache & Imaging • All patients ? →Need Data • New onset • Primary CCH • Atypical history • + Systemic / neurological features

  22. Therapeutics

  23. ABORTIVE THERAPY : SUMATRIPTAN S/C • The Sumatriptan Cluster Headache Study Group -1991 • Success: 74% Sumatriptan 26% Placebo • Modest further benefit from 12mg • 2 & 3mg are effective • No prophylactic benefit • Long term - Well tolerated. • No tachyphylaxis / MOH

  24. ABORTIVE THERAPY : OXYGEN Double-blind cross-over comparison of oxygen 100% inhalation with air 12l / min for 15 minutes ( n=76) * • Success: 78% Oxygen 20% Placebo • Recommendation : 7 – 12 l/min for 15 minutes • CONCLUSION : Safest treatment but impractical Fogan, 1985. / Cohen, 2007*

  25. ABORTIVE THERAPY Sumatriptan 20mg IN Zolmitriptan 5 and 10mg IN Zolmitriptan 5 and 10mg po Lidocaine IN

  26. ABORTIVE THERAPY Sumatriptan 20mg IN Zolmitriptan 5 and 10mg IN Zolmitriptan 5 and 10mg po Lidocaine IN Response at 30 minutes

  27. ABORTIVE THERAPY : LIGNOCAINE IN Double-blind placebo controlled cross-over study Lignocaine 10% Intranasal ( n = 9) 37 ± 7.8 mins Lignocaine} p < 0.01 59.3 ±12.3 mins Placebo } A/Es – Unpleasant taste. Adequate self- administration 4% Lignocaine solution 3-4 drops intranasally Costa et. Al (2000) Cephalalgia ; 20 : 85

  28. PREVENTATIVE THERAPY Multiple daily attacks → Prophylaxis

  29. 240-480mg daily Up to 1200mg daily Start at 80mg tds 40-80mg increments every 10-14 days ECG monitoring every two weeks Lethargy Constipation Pedal oedema Bradycardia PREVENTATIVE THERAPY : VERAPAMIL Leone et al. (2000) Neurology ; 54 : 1382

  30. Verapamil in Cluster Headache Cohen, 2007

  31. 3-6mg : Increase in one week Then 1mg / week Up to 12mg daily BNF – 6 months then drug holiday Nausea and vomiting Abdominal discomfort Vasoconstrictive effects Fibrosis Weight gain Muscle cramps Mood changes PREVENTATIVE THERAPY : METHYSERGIDE

  32. 300-1500mg Level at 4/7 after dose change Weekly until dose constant for 4 weeks Then 3 monthly 0.7-1.2 mmol/l Normal renal function and Na+ (Li toxicity) Tremor GI side effects ↓ thyroid, euthyroid goitre Ataxia, nystagmus, dysarthria Diabetes Insipidus Drowsiness, confusion, seizures PREVENTATIVE THERAPY : LITHIUM

  33. ABORTIVE THERAPY : CORTICOSTEROIDS • Short-term use for multiple daily attacks • Attacks recur once the dose is decreased • 40-80mg for 5 – 7 days • Taper thereafter over 2 weeks • Simultaneously introduce a suitable prophylactic Jammes (1975) Dis. Nerv. Syst. ; 36 : 375

  34. Preventative Therapy • Verapamil – 1200mg daily. ECG monitoring • Methysergide – 12mg daily. Avoid > 6/12 use • Lithium – 300-1500mg ( Level 0.7-1.2mmol/l) • Steroids – 40-80mg. Max. 2 /52. Interim measure • Other considerations → Topiramate / Melatonin / Sodium Valproate / Gabapentin / Ergotamine

  35. SURGICAL THERAPY • Trigeminal ganglion and nerve • Sphenopalatine ganglion • Greater superficial petrosal nerve • Nervus intermedius • Greater Occipital Nerve • Hypothalamus

  36. Greater Occipital Nerve Block

  37. Greater Occipital Nerve Block Ambrosini et al. Pain (2005) AUDIT. Afridi et al. Pain 2006

  38. Occipital Nerve Stimulation Burns, The Lancet (2007)

  39. CLUSTER HEADACHE PET VBM May et al. (1998) Lancet ; 352 : 275 May et al. (1999) Nat. Med; 5:836

  40. Cluster Headache - Stereotactic Stimulation of the Posterior Hypothalamic Gray Matter May et al. (1998) Lancet ; 352 : 275 Leone et al. (2001) NEJM ; 345 : 1428

  41. Cluster Headache Sumatriptan 6mg sc High flow oxygen IN Sumatriptan / IN or Po Zolmitriptan IN Lidocaine Verapamil Methysergide Lithium Topiramate Corticosteroids Local V / Upper Cervical nerve block Local V / Upper Cervical neurostimulation Central neurostimulation

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