Imitrex and Cluster Headache

If you aren't sure as to whether you have clusters vs migraines, here are a few clues:

Cluster patients are usually men and migraineurs are usually women..but not always!

Cluster patients have a one sided headache with a red eye and tears running down the face..oh and a stuffy nose. The pain is a stabbing pain unlike migraine which is throbbing.

The headaches occur very quickly, it takes 15-20 minutes for the pain to become truly bad.

Migraineurs have headaches on one or both sides of the head, and maybe a stuffy nose. They can't stand the light so the prefer to be lying down in a dark room.

Cluster patients can't stand to be still! They like to move around or rock back and forth to try and relieve the stabbing pain.

To break the cycle of cluster headaches, some patients must be on steroids for a few weeks. Many times in our clinic we will give an IV infusion of steroids to break the pain and then put the patient on oral steriods after that.

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 new 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).
Update: Recent research has indicated that occiptal nerve blocks, at the back of the head, may break a cycle of cluster headaches. They may also prevent the return. Ask your doctor to do this simple procedure for you as it works EVEN if you do not have pain at the back of your head.

Cluster headaches are tied to cirdadian rhythms or sleep cycles of the brain. They also occur with changes in the seasons and typically can peak in spring and fall.

A good example of a cluster patient's nightmare can be found at Life at the Headbanger's Ball.

So how does Imitrex and cluster headache work together? Most of my patients use the injectable form to break a headache. The key here is to not take it more than three times a week as there actually is a condition now known as "triptan rebound syndrome", similar to analgesic rebound syndrome.

Many patients prefer to use the Imitrex Nasal Spray and some do well using Zomig Nasal Spray. Generally, I do not recommend the oral versions of these drugs as they simply take too long to get into the system. Remember..these are shorter headaches.

Another abortive therapy that is used in most ER's and in our clinic is oxygen.

Cluster patients respond to a higher dose of oxygen to break a headache, usually 4 liters at least. Why oxygen? Well cluster headaches are vascular like migraines. By overloading the brain with oxygen, the brain has a shut off level and says "too much O2". It will constrict the vessels to slow the oxygen coming to the brain, thereby stopping the headache.

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, you need a drug holiday of a few months and CT scans of the chest and abdomen at regular intervals.

Recently, Topamax has been used in our clinic for 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.

Source:

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

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