Cluster headache

 

Cluster headache - Acute
Rahul Soman, M. Pharm

 

Definition  

Acute Cluster Headache  

Acute attacks of a series of severe, unilateral headache lasting 15 minutes to 2 hours and occurring from once every other day to up to 8 times daily

 

Episodic Cluster Headache  

Attacks occurring in cluster periods lasting 7 days to 1 year, with pain-free intervals of at least 1 month

 

Chronic Cluster Headache  

Cluster attacks occurring for more than 1 year without remission or with remission periods lasting less than 1 month

 

Medical History  

* Alcohol intake - finding

* Smoking

* Caffeine use

* Headache due to high altitude

* Head trauma

* Neck flexion

* Heat exposure

* Family history of Cluster headache

 

Findings  

* Pain of head and neck region

* Bradyarrhythmia - Acute

* Increased blood pressure

* Tachypnea

* Nuchal rigidity

* Pain in eye

* Excessive tear production

* Light intolerance

* Nausea

* Vomiting

* Conjunctival hyperemia

* Horner's syndrome pupil

* Ptosis present

* Nasal congestion

* Nasal discharge

* Intraocular pressure finding

* Warm skin

* Excessive salivation

* Diaphoresis

* Flushing

* Telangiectasia

* Restlessness

* Hyperalgesia

* Leonine facies

 

Tests  

Headache  

* Imaging by body site, Entire brain: Neuroimaging may aid in differential diagnosis of some patients by ruling out specific intracranial abnormalities , but is not universally recommended in all patients with all headache types .

 

Suspected subarachnoid hemorrhage in patients with a negative or equivocal head CT scan  

* Cerebrospinal fluid examination: Findings consistent with subarachnoid hemorrhage include elevated opening pressure, elevated RBC count that does not diminish in successive tubes, and xanthochromia .

 

Meningitis  

* Cerebrospinal fluid examination

 

Suspected giant cell (temporal) arteritis  

* Erythrocyte sedimentation rate measurement: Erythrocyte sedimentation rate is elevated in most, but not all, patients with giant cell arteritis; a normal result does not exclude disease .

 

Differential Diagnosis  

* Subarachnoid hemorrhage

* Bacterial meningitis - Acute

* Temporal arteritis

* Thrombosis of cavernous venous sinus

* Congenital arteriovenous malformation

* Carotid artery dissection

* Neoplasm of cerebrum

* Pheochromocytoma - Acute

* Migraine - Acute

* Glaucoma - Acute

* Postherpetic neuralgia

* Sinusitis - Acute

* Trigeminal neuralgia - Acute

* Postconcussion syndrome

* Chronic paroxysmal hemicrania

 

Treatment  

 

Drug Therapy  

 

Abortive treatment of cluster headache  

 

PROCHLORPERAZINE - DIHYDROERGOTAMINE MESYLATE  

Adults: Prochlorperazine 2.5 to 10 mg IV over 2 to 3 minutes once AND dihydroergotamine (DHE) 1 mg IV or IM; may repeat at 1-hour intervals (maximum 3 mg IM/day or maximum of 2 mg IV/day) OR DHE 0.5 mg spray per nostril and repeated in each nostril after 15 minutes for a total dose of 2 mg OR DHE 1 mg subQ in abdomen or thigh by self-injection (maximum 5 mg/week)

 

SUMATRIPTAN  

Adults: 6 mg subQ; may repeat after 1 hour (maximum 12 mg/24 hours) OR 20 mg intranasally; may repeat after 2 hours (maximum 40 mg/24 hours)

 

ERGOTAMINE TARTRATE  

Adults: 2 mg SL initially then 2 mg repeated in 30 to 60 minutes if required (maximum 6 mg/day and 10 mg/week) OR 1 suppository (2 mg) rectally; may repeat once after 30 to 60 minutes if required (maximum 5 suppositories/week or 10 mg/week)

 

Prevention of cluster headache  

 

PREDNISONE  

Adults: 40 to 60 mg/day orally in a single morning dose, then decrease dose slowly over 3 weeks

 

VERAPAMIL HYDROCHLORIDE  

Adults: 240 mg/day orally in 1 or 2 doses (long-acting preparation), or higher doses to control chronic cluster headaches

 

ERGOTAMINE TARTRATE  

Adults: 2 mg orally 1 to 2 hours before bedtime (maximum 5 doses/week)

 

Procedural Therapy  

 

Acute cluster headache  

* Oxygen therapy: Oxygen administration is the treatment of choice for acute cluster headaches and is one of the most efficacious methods for symptom abatement .