Cluster headache

Symptoms & causes Diagnosis & treatment Doctors & departments Care at Vejthani

Overview 

Cluster headaches are among the most excruciating forms of headaches, often occurring in cyclical patterns called cluster periods. Typically, these headaches awaken individuals during the night, causing severe pain around one eye on a specific side of the head. These cluster periods involve frequent attacks lasting for weeks to months, followed by periods of relief when the headaches subside. These remission phases can extend across several months or even years.

Healthcare providers classify both types of headaches as primary headaches rather than secondary headaches. The distinction is as follows:

Primary headaches: They start when the part of the brain that deals with pain becomes active. A primary headache is its own health issue and isn’t connected to a bigger problem.
Secondary headaches: They begin due to another health problem. Many things can cause these headaches, like ear infections, stuffy noses, and not having enough water in your body.

Fortunately, cluster headaches are rare and not life–threatening. Effective treatments are available to alleviate the intensity and duration of cluster headache episodes. Medications are also prescribed to reduce the frequency of cluster headaches.

Symptoms 

Rapid and often unexpected, a cluster headache might be preceded by migraine–like nausea and aura. Typical signs and symptoms experienced during such a headache include:

Intense, one–sided pain around the eye.
Restlessness.
Excessive tearing.
Redness in the affected eye.
Stuffy or runny nose on the same side.
Facial sweating.
Pale or flushed skin on the face.
Swelling around the eye.
Drooping eyelid on the affected side.

Cluster periods typically last for weeks to months, with consistent timing and duration. They can be seasonal, like every spring or fall. Most individuals experience episodic cluster headaches lasting a week to a year, followed by a pain–free period of 3 months or more before the next headache.

Chronic clusters can persist for over a year, with pain–free periods under a month. During a cluster period:

Daily headaches, often multiple times
Attacks last 15 minutes to 3 hours
Regular timing, mostly at night, 1 to 2 hours after sleep
Pain ends suddenly, leaving exhaustion.

Immediate medical attention is necessary if you experience any of these indications:

Suddenly intense headache, often described as a thunderclap
Headache accompanied by fever, nausea, vomiting, a stiff neck, confusion, seizures, numbness, or difficulty speaking; these could indicate various issues like stroke, meningitis, encephalitis, or a brain tumor
Headache following a head injury, even minor ones, particularly if it gets worse
Rapid onset of an extremely severe headache that differs from your usual headaches
Headache that worsens gradually over several days and changes its usual pattern

Causes 

The exact cause of cluster headaches remains elusive, but their pattern suggests involvement of abnormalities in the body’s biological clock, centered in the hypothalamus. Unlike migraines and tension headaches, cluster headaches are not commonly associated with triggers such as dietary elements, hormonal shifts, or stress. However, alcohol consumption can rapidly trigger severe headaches once a cluster period begins, leading many with cluster headaches to avoid alcohol during these episodes. Other potential triggers encompass the use of medications like nitroglycerin, typically prescribed for heart disease.

Risk factors 

Several risk factors may affect one’s susceptibility to getting cluster headaches, such as: 

Family history: The risk of cluster headache is higher when a family member has experienced one.
Sex: Previously, researchers believed that these headaches were more common among men. They now believe they have an equal impact on men and women.
Age: While the condition can strike at any age, it commonly affects people between the ages of 20 and 50. Symptoms typically appear at these ages.
Tobacco use: People who smoke are more prone to getting cluster headaches.
Alcohol use: Consuming alcohol during a cluster period may increase the likelihood of having an attack.

Diagnosis 

The diagnosis of a cluster headache usually involves a comprehensive examination, which may require providing details of the attacks, the level of pain, headache location, intensity, frequency, duration, and accompanying symptoms.

Cluster headaches exhibit a distinctive pain quality and attack pattern. To determine the type and cause, tests and procedures may be necessary, such as:

Neurological examination: This exam will check how well the brain works using a variety of tests, including assessing the senses, reflexes, and nerves. This may assist in detecting physical indicators of a neurological illness. In most cluster headache sufferers, the exam is normal.
Imaging tests: These tests may be recommended to rule out more dangerous causes of head pain, such as a tumor or aneurysm. This is usually done if one has uncommon or challenging headaches or an abnormal neurological exam. Additional tests may include:
Magnetic Resonance Imaging (MRI): This procedure generates comprehensive images of internal body structures such as blood vessels and the brain, utilizing a powerful magnet, radio waves, and computer technology.
Computed Tomography (CT) scan: A CT scan is a painless and noninvasive procedure that provides detailed images of the brain using a series of X-rays and a computer.

Treatment 

Cluster headaches currently have no known cure. Treatment aims to reduce pain severity, shorten headache duration, and prevent attacks. Due to the rapid onset and short duration of these headaches, prompt–acting medications are necessary. Certain acute medications can offer rapid pain relief. The following therapies are highly effective for both immediate and preventive cluster headache treatment.

Acute treatments

Fast–acting treatments prescribed by your doctor include:

Oxygen: Inhaling pure oxygen through a mask offers rapid relief, typically within 15 minutes. Carrying oxygen equipment might be inconvenient.
Triptans: Injectable sumatriptan and nasal spray zolmitriptan, used for migraines, are effective for acute cluster headache. Sumatriptan injections are usually preferred.

Octreotide: An injectable synthetic version of somatostatin, octreotide provides relief for some, though it’s slower and less effective than triptans.
Local anesthetics: Intranasal lidocaine, a numbing agent, can help with cluster headache pain in some cases.
Dihydroergotamine: Injectable dihydroergotamine may relieve cluster headache pain, but the inhaled form isn’t proven effective.

Preventive treatments

Preventive treatments for cluster headaches focus on suppressing attacks:

Calcium channel blockers: Verapamil is commonly used to prevent cluster headaches, especially in chronic cases. It might be combined with other drugs and may require longer–term use. Side effects include constipation, nausea, fatigue, ankle swelling, and low blood pressure.
Corticosteroids: Fast–acting drugs like prednisone can help those with recent onset or brief cluster periods. Due to serious side effects, they’re unsuitable for prolonged use.
Lithium carbonate: Used for bipolar disorder, it’s an option if other treatments fail for chronic cluster headache. Side effects like tremors can be managed through dosage adjustments, with regular blood checks.
Noninvasive vagus nerve stimulation (VNS): Delivering electrical stimulation to the vagus nerve through the skin with a handheld controller may reduce cluster headache frequency, although more research is needed.
Nerve block: Injecting anesthetic and corticosteroids around the occipital nerve at the back of the head can temporarily improve chronic cluster headaches, often used alongside verapamil.
Other options: Anti–seizure medications like topiramate might be used for prevention.

Surgery

In rare cases, surgery might be recommended for chronic cluster headache sufferers who don’t respond well to aggressive treatment or cannot tolerate medications or their side effects.

Sphenopalatine ganglion stimulation: This involves implanting a neurostimulator controlled by a handheld device. Some research suggests it can provide quick pain relief and reduce headache frequency, but further studies are required.
Occipital nerve stimulation: Implanting an electrode near one or both occipital nerves has shown potential benefits in small studies.
Nerve pathway–damaging procedures: Some surgical methods target nerve pathways believed to cause pain, like the trigeminal nerve around the eye. However, the long–term effectiveness of these procedures is debated, and complications like muscle weakness or sensory loss make them rarely considered.

Possible future treatments

Researchers are investigating potential treatments for cluster headaches:

Occipital nerve stimulation: Electrodes are implanted in the back of the head, connected to a generator. These electrodes stimulate the occipital nerve area, potentially blocking pain signals. Some small studies showed pain reduction and headache frequency decrease in chronic cluster headache patients.
Deep brain stimulation: This unproven approach is considered for cluster headaches resistant to other treatments. An electrode is placed in the hypothalamus, linked to a generator altering brain impulses to alleviate pain. The procedure carries risks due to its deep brain placement, including infection or hemorrhage. It may help those with severe, treatment-resistant chronic cluster headaches.

Diseases & Conditions Cluster headache