Cluster headache is a rare type of primary headache, affecting 0.1% of the population. An estimated 85% of cluster headache sufferers are men. The average age of cluster headache sufferers is 28-30 years, although headaches may begin in childhood. It also does not have a clear cause, although alcohol and cigarettes can precipitate attacks.
Cluster headaches are headaches that come in groups (clusters) lasting weeks or months, separated by pain-free periods of months or years. During the period in which the cluster headaches occur, pain typically occurs once or twice daily, but some patients may experience pain more than twice daily. Each episode of pain lasts from 30 minutes to one and one-half hours. Attacks tend to occur at about the same time every day and often awaken the patient at night from a sound sleep . The pain typically is excruciating and located unilaterally around or behind one eye. Some patients describe the pain as feeling like a hot poker in the eye. The affected eye may become red, inflamed, and watery. The nose on the affected side may become congested and runny. Unlike patients with migraine headaches, patients with cluster headaches tend to be restless. They often pace the floor, bang their heads against a wall, and can be driven to desperate measures. Cluster headaches are much more common in males than females.
There are two approaches to treating cluster headaches: abortive and prophylactic. Abortive treatment is taken to stop the headaches. Prophylactic treatment is used to abolish or shorten the cycle of headaches.
Abortive treatments include inhalation of 100% oxygen at 8-10 liters/minute using a non-rebreathing facemask for 10-15 minutes along with a triptan such as sumatriptan (nasally, or under the skin) or an ergot such as DHE (intravenously, under the skin, or intramuscularly).
A calcium channel blocker, verapamil (Calan, Verelan, Isoptin) is the medication of choice for prophylactic treatment of cluster headaches. Other prophylactic medications include valproate, ergotamine, lithium and methysergide. On occasion, verapamil may be combined with another prophylactic medication. Prophylactic medications usually are begun early during a cycle of cluster headaches and continued for two weeks longer than the usual cycle. The dose of medication then is reduced gradually. Because prophylactic medications may take two weeks to be effective, prednisone (a corticosteroid) often is used in decreasing doses for the first two weeks of treatment. Prednisone often can quickly abolish the headaches.
Secondary headaches have diverse causes, ranging from serious and life threatening conditions such as brain tumors, strokes, meningitis (brain infection), and subarachnoid hemorrhages (bleeding in the brain) to less serious but common conditions such as high blood pressure, withdrawal from caffeine and discontinuation of analgesics. Timely and accurate diagnosis of secondary headaches is important.
Many people suffer from "mixed" headache disorders in which tension headaches or secondary headaches trigger migraine headaches.
Many people who suffer from mild headaches medicate themselves with over-the-counter analgesics, and they usually do not seek medical care. Nevertheless, the symptoms of primary headaches and secondary headaches can overlap. Furthermore, a person with a long history of migraine or tension headaches can develop a new secondary headache. Many tension or sinus headaches probably are migraine headaches and will respond to treatments that are specific for migraine. Therefore, a doctor should be consulted if the headache is:
- Severe ("the worst ever")
- Different than the usual headaches
- Starts suddenly during exertion
- Aggravated by exertion, coughing, bending, or sexual activity
- Associated with persistent nausea and vomiting
- Associated with stiff neck, fever, dizziness, blurred vision, slurred speech, unsteady gait, weakness or unusual sensations of the arm or leg, excessive drowsiness or confusion
- Associated with seizures
- Associated with recent head trauma or a fall
- Not responding to treatment and is getting worse
- Disabling, and interfering with work and the quality of life
- Requires more than the recommended dose of over-the-counter analgesics for relief
There are two ways to prevent migraine headaches: 1) by avoiding factors ("triggers") that cause the headaches, like stress, sleep disturbances, fasting, hormones, bright or flickering lights, odors, cigarette smoke, alcohol, aged cheeses, chocolate, monosodium glutamate, nitrites, aspartame, and caffeine; and 2) by preventing headaches with medications (prophylactic medications). Neither of these preventive strategies is 100% effective. The best one can hope for is to reduce the frequency of headaches.
Individuals with mild and infrequent migraine headaches that do not cause disability may require only OTC analgesics. Individuals who experience several moderate or severe migraine headaches per month or whose headaches do not respond readily to medications should avoid triggers and consider modifications of their life-style. Life-style modifications for migraine sufferers include:
- Go to sleep and waking up at the same time each day.
- Exercise regularly (daily if possible). Make a commitment to exercise even when traveling or during busy periods at work. Exercise can improve the quality of sleep and reduce the frequency and severity of migraine headaches. Build up your exercise level gradually. Over-exertion, especially for someone who is out of shape, can lead to migraine headaches.
- Do not skip meals, and avoiding prolonged fasting.
- Limit stress through regular exercise and relaxation techniques.
- Limit caffeine consumption to less than two caffeine-containing beverages a day.
- Avoid bright or flashing lights and wearing sunglasses if sunlight is a trigger.
- Identify and avoid foods that trigger headaches by keeping a headache and food diary. Review the diary with your doctor. It is impractical to adopt a diet that avoids all known migraine triggers, however, it is reasonable to avoid foods that consistently trigger migraine headaches.
Tension headaches have not been shown to lead to neurological dysfunction or brain damage. In general, this is true of migraine headaches. However, there is a rare association of migraine headaches and stroke, particularly in sufferers of complicated migraines. While cluster headaches need to be differentiated from more serious neurological conditions, there is no known danger of cluster headaches leading to stroke.
Reference: The medical clinics of North America "Headache", Ninan T. Mathew, MD, July 2001.Medically Reviewed by: Joseph Carcione, D.O., M.B.A., Board Certified Neurology
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