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Chronic Cluster Headache

Chronic cluster headache occurs in about 10% to 20% of cluster headache patients who have headaches that lasts more than a year. Most of the time, people with this type of headache suffer from episodic attacks which occur with the changes of the seasons. In other words they happen spring and fall, or less often, summer and winter.

Acute cluster headache occurs mostly in men over the age of 40. They seem to have a particular body type of barrel chested, a thicker neck and up to 30% have hazel eyes. There is a definite circadian rhythm to this type of headache. Most patients have them occur during the spring or fall months but some will have them in summer or winter months.

At the present time medical science is not quite sure as to why this happens. Another rhthym that occurs is that when the pain starts, it occurs at the same time everyday or twice a day. Most people when questioned say the headaches awaken them in the middle of the night with severe pain and then may occur again twelve hours later in the middle of the afternoon. More severe cases will have them several times a day.

Take a look at the photo below and you can see the pathology of the headache as one sided with redness and tearing in the eye in addition to nasal congestion all on the same side. These headaches have been termed "suicide headaches" as the pain is so excruitiating and severe. Cluster headaches last from 30-180 minutes and then subside to no pain at all. This is what differentiates them from migraines which last 4-72 hours.

Additionally, cluster patients want to move around while migraineurs must lie still in a quiet dark room. There is an even rarer headache known as cluster migraine variant.

Chronic patients are different. These patients have remissions lasting less than 14 days. Two chronic subtypes have been defined:

  • Chronic cluster headache that is unremitting from the onset.This type may be more commonly associated with heavy alcohol use.
  • Chronic cluster headache that has evolved from episodic cluster.

One study found a higher risk of transforming from episodic to chronic in patients who developed cluster headaches in their thirties or older and who had more frequent attacks and shorter remissions than average. Another study suggested that this condition occurs more often in heavy smokers, although the link is uncertain.

Treatments At Onset Of Headache

The treatment of chronic cluster headaches is usually a bit more lengthly and more aggressive than a routine bout of cluster that lasts for a month or so.

  • Sumatriptan (Imitrex)

Sumatriptan is best when used in the injectable form. Since cluster headaches are short, less than 180 minutes, oral medication at the onset is usually not too effective. Injectable has a time of onset of 10-12 minutes.

  • Oxygen therapy.

Most people keep a tank of oxygen at home and use O2, 7-10liters/min by mask for 10 minutes at the onset of a bad headaches.

  • DHE (dihydroergotamine)

In this case,k either injectable or nasal spray is effective. Once again, injectable has the fastest onset of action.

  • Steroids

For these patients, two or three days of successive IV infusions of steroid may be required, followed by several weeks of steroid. If prednisone is not successful, then dexamethasone should be tried. At the same time, oral medications such as verapamil and/or lithium could be very effective. Occipital nerve blocks have also been quite sucessful in breaking this cycle of headaches.

cluster headache, chronic cluster headache

Preventative Treatments

Dont lose hope! Recent studies have indicated that occipital stimulation may have good effect in preventing chronic cluster headaches. Until available generally, you might want to talk to your doctor about occipital nerve blocks as several of these would serve the same purpose.

You might also talk to your doctor about using lithium as a while to break these headaches..although a medication not generally used for cluster, it might be effective for you. You most probably would have to be on it for a few months and then could discontinue it.

  • Verapamil

Another great medication for clusters is Verapamil. This is an anti-hypertensive used to prevent clusters. A common mistake many health care professionals make is to under dose patients with this drug. For hypertension the dose is once a day but with cluster patients we give them two or three doses per day with great effects. For some reason, it does not lower blood pressure if your pressure was normal to begin with. Heart rate however, can be slower on this drug.

One of the side effects of this drug can be constipation, and perhaps decreased exercise tolerance. The body adapts to this over time and these effects can diminish.

Warning: A study released in the Journal of Neurology indicates that up to 19% of patients on higher dosed Verapamil for cluster headaches may develope a cardiac arrhythmia. You should be monitored with an EKG during treatment. You should not take this medication if you have a pre-existing arrhythmia (irregular heart rate).

  • Sansert
This was a drug that used to be available in the US and was excellent to treat chronic cluster headaches. Unfortunately, it is no longer in the US but IS available in Canada and other countries. It is taken daily for several months and then the patient has a 'drug holiday' to avoid the adverse reaction of fibrosis.

This drug has the unfortunate adverse reaction of causing fibrosis (or scar tissue) of internal organs in about 2-5% of users. If you are on this drug, after the drug holiday of a few months and CT scans of the chest and abdomen. If all is normal and your provider feels you still need treatment then you can resume the medication.

  • Topamax
Recently, Topamax has been used in our clinic for chronic cluster headache, but only in conjuction with another medication such as steroids or verapamil.

We do not start treatment with Topamax alone, but when added on to other treatments it seems to have a beneficial effect.

If this doesn't sound like you, read more about different types of headaches.

References:

Goadsby, P.J., Effects of Verapamil on Cluster Headache. Journal of Neurology. August 2007



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