Management Of Cluster Headache Research Articles

Prevalence, Risk Factors, and Management of Cluster headache; A systematic Review

Cluster headache (CH) is intricately linked to diverse risk factors, spanning hereditary, environmental, and lifestyle elements. This systematic study, guided by PRISMA guidelines, delves into the prevalence, risk factors, and management of CH. Examining English-language articles from 2010 to 2023 via PubMed/Medline, Scopus, and Embase, our findings reveal a significant association between cluster headaches and factors including family history, smoking, alcohol consumption, male predominance, and head trauma. Notably, a reevaluation of sex discrimination in familial cases is warranted, given the observed female predominance in familial history and CH association studies. Reviewing 739 studies, 7 met inclusion criteria, predominantly utilizing surveys and national database analyses (n=7). Improving our grasp of diagnosis and treatment holds promise for future evaluation and management. Our conclusion underscores global variability in CH prevalence, urging more rigorous population-based surveys. The substantial and persistent burdens associated with CH, from suicidality to economic stress, underscore the need for comprehensive research and intervention. CH transcends the label of a mere \"trigeminal autonomic headache,\" showcasing a diverse spectrum of attack and bout characteristics across countries and ethnicities. Despite the global efficacy of current diagnostic criteria, CH emerges as a dynamic illness, demonstrating progression or regression over time. This underscores the necessity for further research in comprehending its trajectory.

Effects of Non-Invasive Neuromodulation of the Vagus Nerve for the Management of Cluster Headache: A Systematic Review.

Cluster headache (CH) is a type of headache that has a global prevalence of 0.5-3/1000 people, provokes severe, strictly unilateral pain through the first branch of the trigeminal nerve, and is associated with observable autonomous responses. CH provokes intense pain and decreases quality of life. In this study, we aimed to carry out a systematic review of the effectiveness of non-invasive neuromodulation of the vagus nerve in patients with cluster headaches, which was registered on PROSPERO No. CRD42021265126. Six databases were used from their date of inception to February 2023 to obtain studies with the group intervention of non-invasive neuromodulation of the vagus nerve for cluster headache, with outcomes based on pain attacks, duration, and disabilities. Data on the subjects, group intervention, main outcomes, and results were collected by two authors. The search provided 1003 articles, with three clinical trials being eligible for inclusion in the review. The methodological quality scores ranged from 6 to 8 points (mean: 7.3, SD: 0.8) out of a maximum of 10 points. The post-treatment results showed some positive effects using n-VNS as a treatment for cluster headache, more specifically regarding cervical neuromodulation of the vagus nerve. The systematic review found moderate-to-high-quality evidence supporting that n-VNS and cervical n-VNS may have some positive effects at the end of the treatment being effective to relieve the frequency and intensity of cluster headaches. The poor quantity of studies available and the lack of homogeneity in the study protocols did not allow the pooling of data for a meta-analysis.

Management of cluster headache: Treatments and their mechanisms.

The management of cluster headache is similar to that of other primary headache disorders and can be broadly divided into acute and preventive treatments. Acute treatments for cluster headache are primarily delivered via rapid, non-oral routes (such as inhalation, nasal, or subcutaneous) while preventives include a variety of unrelated treatments such as corticosteroids, verapamil, and galcanezumab. Neuromodulation is becoming an increasingly popular option, both non-invasively such as vagus nerve stimulation when medical treatment is contraindicated or side effects are intolerable, and invasively such as occipital nerve stimulation when medical treatment is ineffective. Clinically, this collection of treatment types provides a range of options for the informed clinician. Scientifically, this collection provides important insights into disease mechanisms. Two authors performed independent narrative reviews of the literature on guideline recommendations, clinical trials, real-world data, and mechanistic studies. Cluster headache is treated with acute treatments, bridge treatments, and preventive treatments. Common first-line treatments include subcutaneous sumatriptan and high-flow oxygen as acute treatments, corticosteroids (oral or suboccipital injections) as bridge treatments, and verapamil as a preventive treatment. Some newer acute (non-invasive vagus nerve stimulation) and preventive (galcanezumab) treatments have excellent clinical trial data for episodic cluster headache, while other newer treatments (occipital nerve stimulation) have been specifically tested in treatment-refractory chronic cluster headache. Most treatments are suspected to act on the trigeminovascular system, the autonomic system, or the hypothalamus. The first-line treatments have not changed in recent years, but new treatments have provided additional options for patients.

Methylphenidate as a potential treatment for cluster headache

Cluster headache is a potentially debilitating condition that can lead to restrictions in occupational and day‐to‐day function. Here, the authors outline a case of a significant reduction in headache frequency in a patient who had an incomplete response to NICE‐recommended treatments, and was treated for attention deficit hyperactivity disorder with stimulant medications. This article builds on a small number of case reports indicating a potential role for stimulant medications such as methylphenidate in the management of cluster headache.

Comparative Impact of Pharmacological Therapies on Cluster Headache Management: A Systematic Review and Network Meta-Analysis.

It is important to find effective and safe pharmacological options for managing cluster headache (CH) because there is limited evidence from studies supporting the general efficacy and safety of pharmacological therapies. This systematic review and network meta-analysis (NMA) analyzed published randomized controlled trials (RCTs) to evaluate the efficacy and safety of pharmacological treatments in patients with CH. The PubMed and Embase databases were searched to identify RCTs that evaluated the efficacy and safety of pharmacological treatments for CH. Efficacy outcomes included frequency and duration of attacks, pain-free rate, and the use of rescue agents. Safety outcomes were evaluated based on the number of patients who experienced adverse events. A total of 23 studies were included in the analysis. The frequency of attacks was reduced (mean difference (MD) = −1.05, 95% confidence interval (CI) = −1.62 to −0.47; p = 0.0004), and the pain-free rate was increased (odds ratio (OR) = 3.89, 95% CI = 2.76–5.48; p < 0.00001) in the pharmacological treatment group, with a lower frequency of rescue agent use than the placebo group. Preventive, acute, and triptan or non-triptan therapies did not show significant differences in efficacy (p > 0.05). In the NMA, different results were shown among the interventions; for example, zolmitriptan 5 mg was more effective than zolmitriptan 10 mg in the pain-free outcome (OR = 0.40, 95% CI = 0.19–0.82; p < 0.05). Pharmacological treatment was shown to be more effective than placebo to manage CH with differences among types of therapies and individual interventions, and it was consistently shown to be associated with the development of adverse events. Thus, individualized therapy approaches should be applied to treat CH in real-world practice.

Management of cluster headache and other trigeminal autonomic cephalalgias in pregnancy and breastfeeding.

Many clinicians lack experience in managing trigeminal autonomic cephalalgias (TACs) in pregnancy and lactation. In addition to cluster headache, TACs include hemicrania continua, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/autonomic symptoms (SUNCT/SUNA). Treating these rare, severe headache conditions often requires off-label drugs that have uncertain teratogenic potential. In the last few years, several new treatment options and safety documentation have emerged, but clinical guidelines are lacking. This narrative review aimed to provide an updated clinical guide and good clinical practice recommendations for the management of these debilitating headache disorders in pregnancy and lactation.

Current advances in the management of cluster headaches

ABSTRACT Introduction: Cluster headache (CH) is probably the most severe idiopathic pain condition, yet its current medical management remains poor. Areas covered: Only repurpose medicines are currently in use for the prevention of CH, partially because the pathophysiology of the condition is still elusive. In this article we performed a systematic review to evaluate the evidence for efficacy of the currently available or emerging treatments for CH. Expert opinion: We found several ongoing randomized clinical trials testing prophylactic treatments for CH and only few for the standard ones. Recent data from randomized trials with monoclonal antibodies targeting the calcitonin gene related peptide pathway (anti-CGRP mAbs) are controversial, although its role in the pathogenesis of the condition is well documented. This inconsistency may depict inadequacies in clinical trial designing. Anti-CGRP mAbs and antagonists of pituitary adenylate cyclase-activating polypeptide (PACAP) along with neuromodulation techniques, are curing the necessary valuable evidence that could illuminate the therapeutical future for cluster headache. Orexin pathway is another attractive target for CH treatment. To improve the evidence for efficacy, we further propose that the design of the clinical trials for CH needs to be radically reviewed to allow more patients to participate.

New Management of Cluster Headache

Galcanezumab, a CGRP monoclonal antibody drug, has been approved by the U.S. Food and Drug Administration (FDA) for the prevention of recurrent cluster headaches. This was done after a randomized, double-blind, placebo-controlled trial found it to be effective and safe. Similarly sphenopalatine ganglion stimulation has been found to be effective and safe in a randomized, controlled trial as an acute treatment for chronic cluster headache. This article reviews the mechanisms of action of these therapies and their clinical trial results, clinical uses, and prospects in Japan.

Cluster headache pathophysiology - insights from current and emerging treatments.

Cluster headache is a debilitating primary headache disorder that affects approximately 0.1% of the population worldwide. Cluster headache attacks involve severe unilateral pain in the trigeminal distribution together with ipsilateral cranial autonomic features and a sense of agitation. Acute treatments are available and are effective in just over half of the patients. Until recently, preventive medications were borrowed from non-headache indications, so management of cluster headache is challenging. However, as our understanding of cluster headache pathophysiology has evolved on the basis of key bench and neuroimaging studies, crucial neuropeptides and brain structures have been identified as emerging treatment targets. In this Review, we provide an overview of what is known about the pathophysiology of cluster headache and discuss the existing treatment options and their mechanisms of action. Existing acute treatments include triptans and high-flow oxygen, interim treatment options include corticosteroids in oral form or for greater occipital nerve block, and preventive treatments include verapamil, lithium, melatonin and topiramate. We also consider emerging treatment options, including calcitonin gene-related peptide antibodies, non-invasive vagus nerve stimulation, sphenopalatine ganglion stimulation and somatostatin receptor agonists, discuss how evidence from trials of these emerging treatments provides insights into the pathophysiology of cluster headache and highlight areas for future research.

The impact of the disease burden on the quality of life of cluster headache patients

Background: Cluster headache cannot be cured, and not all attacks can be aborted or prevented. Nevertheless, therapeutic guidelines focus solely on the attacks and ignore reverberations of the disorder on patients’ lives. However, it is likely that not only pain reduces patients’ quality of life (QoL). Objective: To investigate whether the interictal burden independently influence the QoL of subjects suffering from cluster headache. Methods: In this cross-sectional study, we asked patients with a self-reported cluster headache diagnosis to answer a modified EUROLIGHT questionnaire that included the EURO-HIS QoL scale. We built a generalised linear model and included the QoL as the dependent variable. Independent variables comprised both the ictal and the interictal burden. Results: The data of 625 participants entered the analysis. Several aspects of the interictal burden independently reduced the QoL. Among them were fear of pain, self-concealment, and private life difficulties due to the disorder. Conclusion: Both the ictal and the interictal burden of cluster headache independently reduce patients’ QoL. We advocate adopting a more holistic approach to cluster headache management extending the focus towards the afflicted person and their QoL, which would generate novel therapeutic goals and strategies, complementary to treating and preventing cluster headache attacks.

Emerging treatments for cluster headache: hopes and disappointments.

Cluster headache stands among the worst debilitating pain conditions. Available treatments for cluster headache have often disabling side effects, are not tolerated, or are ineffective. The management of drug-refractory chronic forms is challenging. New treatments are warranted and reported here. In cluster headache acute treatment, delivery systems like Demand Valve Oxygen or nonrebreather-type masks could enhance the effectiveness of inhaled oxygen therapy. Noninvasive vagus nerve stimulation relieves cluster headache pain at short-term in episodic patients. Sphenopalatine ganglion stimulation combines acute and preventive properties in subsets of patients and is of interest in selected refractory chronic forms. In cluster headache prevention, 'hypothalamic' deep brain stimulation is being refined using slightly different stereotactic coordinates or lower risk methods like endoventricular stimulation. Anti-CGRP monoclonal antibodies provide interesting results in episodic cluster headache, have a good safety profile, but do not appear effective in chronic cluster headache. These novel approaches provide additional alternatives to conventional cluster headache management, but results obtained in chronic forms are often disappointing. Research on cluster headache is often hampered by the lack of awareness in the medical world and by the relatively low prevalence of cluster headache compared with migraine. However, common features shared by these two primary headaches could help developing disease-specific therapies.

Cluster headache is associated with unhealthy lifestyle and lifestyle-related comorbid diseases: Results from the Danish Cluster Headache Survey.

To compare the prevalence of unhealthy lifestyle factors and comorbid disorders in cluster headache patients with headache-free controls, in order to discuss pathophysiology and possible consequences. Cluster headache patients from the Danish cluster headache survey aged 18-65 years, diagnosed according to ICHD-II, were compared to sex- and age-matched headache-free controls. Participants completed questionnaires and structured interviews. A total of 400 cluster headache patients and 200 controls participated. Patients had a more unhealthy lifestyle compared with controls in the form of current and current/former smoking (48.3% vs. 9.0%, p < 0.001 and 74.5% vs. 30.0%, p < 0.001, respectively), higher average alcohol intake per week (98.2 grams vs. 77.9 grams, p = 0.033) and BMI (26.1 vs. 24.2 kg/m2, p < 0.001), whereas coffee and energy drink consumption was equally distributed. Further, lifestyle-related, psychiatric and pain-related diseases were much more prevalent in patients compared with controls, except for diabetes. Sub-group analyses revealed that current/former smokers had a worse clinical presentation than never smokers. Unhealthy lifestyle factors and lifestyle-related diseases were more prevalent in cluster headache patients compared to controls. As lifestyle-related diseases might have serious consequences in the management of cluster headache, it is key to inform patients at an early time point about the possible risks of their lifestyle choices.

Noninvasive vagus nerve stimulation in the management of cluster headache: clinical evidence and practical experience.

The efficacy of invasive vagal nerve stimulation as well as other invasive neuromodulatory approaches such as deep brain stimulation, occipital nerve stimulation, and ganglion sphenopalatine stimulation has been shown in the treatment of headache disorders in several studies in the past. However, these invasive treatment options were quite costly and often associated with perioperative and postoperative side effects, some severe. As such, they were predominantly restricted to chronic and therapy refractory patients. Transcutaneous vagal nerve stimulation now offers a new, noninvasive neuromodulatory treatment approach. Recently published studies showed encouraging results of noninvasive vagus nerve stimulation (nVNS), especially with respect to cluster headache, with high tolerability and a low rate of side effects; however, randomized controlled trials are needed to prove its efficacy. Further data also indicate therapeutic benefits regarding treatment of migraine and medication overuse headache. This review summarizes current knowledge and personal experiences of nVNS in the treatment of cluster headache.

Cluster Headache: Special Considerations for Treatment of Female Patients of Reproductive Age and Pediatric Patients.

Cluster headache is a rare disorder that is more common in adult male patients. It has a unique phenotype of unilateral, severe, to very severe headaches lasting 15 to 180 min with ipsilateral autonomic symptoms. Time to correct diagnosis can be protracted. A number of treatment options exist for the standard cluster headache patient, but special considerations must be made for female patients of reproductive age and pediatric patients. The objective of this article is to explore the current literature pertaining to special considerations in cluster headache management, including treatment of pregnant or breastfeeding patients and pediatric patients.

Amitriptyline in the Management of Cluster Headache (P3.055)

Amitriptyline in the Management of Cluster Headache (P3.055)

EHMTI-0357. Perceptions and experiences of cluster headache among patients, general practitioners and neurologists in the north of england: a qualitative study

Result This study runs from August 2014 to June 2015 and data collection is currently in process. Therefore all results are tentative. Early findings show that this study sheds new light on the following aspects: early detection and diagnosis; health education and promotion; effective treatment and management of cluster headaches. Conclusion This study will identify the particular challenges for each stakeholder group—patients, general practitioners and neurologists—with respect to early detection of cluster headaches and ways in which treatment and management can be facilitated. We envisage this study will raise awareness about the importance of early diagnosis, health education and the need for effective treatment pathways for cluster headaches.

Pharmacotherapy Options for the Management of Cluster Headache

Cluster headache is a primary headache syndrome characterized by attacks of severe unilateral headache typically lasting 30 to 180 minutes without treatment and prominent autonomic symptoms on the affected side. Often attacks occur in cycles lasting weeks to months with up to 8 attacks per day, and a minority of individuals continue to experience attacks throughout the year. Persons with cluster headache usually require both acute medication for attacks and preventive treatment to keep the headaches from occurring. Subcutaneous sumatriptan is the most effective medication for acute cluster attacks, but other triptans such as zolmitriptan nasal spray are also effective. inhaling 100% oxygen is also effective and is a useful treatment for those with frequent attacks or contraindications to triptans. Corticosteroids are among the most effective transitional treatments, typically used at the start of a cycle. Dihydroergotamine is an effective treatment for refractory or severe cluster headache with multiple attacks requiring large triptan doses. Verapamil and lithium are among the most effective preventive medications with good evidence of effectiveness, but other studies support the use of gabapentin, topiramate, diavalproex sodium, and methysergide, to name a few. Each of these medications requires monitoring for adverse events and can be discontinued within a few weeks of a cluster headache cycle.

Diagnosis and management of cluster headache

Cluster headache is a severe, disabling headache disorder, and current evidence suggests that it remains poorly diagnosed and managed. The aim of this article is to increase awareness of this disorder by identifying the key diagnostic features and current acute and prophylactic treatments available.

Management of Cluster Headache

The prevalence of cluster headache is 0.1% and cluster headache is often not diagnosed or misdiagnosed as migraine or sinusitis. In cluster headache there is often a considerable diagnostic delay - an average of 7 years in a population-based survey. Cluster headache is characterized by very severe or severe orbital or periorbital pain with a duration of 15-180 minutes. The cluster headache attacks are accompanied by characteristic associated unilateral symptoms such as tearing, nasal congestion and/or rhinorrhoea, eyelid oedema, miosis and/or ptosis. In addition, there is a sense of restlessness and agitation. Patients may have up to eight attacks per day. Episodic cluster headache (ECH) occurs in clusters of weeks to months duration, whereas chronic cluster headache (CCH) attacks occur for more than 1 year without remissions. Management of cluster headache is divided into acute attack treatment and prophylactic treatment. In ECH and CCH the attacks can be treated with oxygen (12 L/min) or subcutaneous sumatriptan 6 mg. For both oxygen and sumatriptan there are two randomized, placebo-controlled trials demonstrating efficacy. In both ECH and CCH, verapamil is the prophylactic drug of choice. Verapamil 360 mg/day was found to be superior to placebo in one clinical trial. In clinical practice, daily doses of 480-720 mg are mostly used. Thus, the dose of verapamil used in cluster headache treatment may be double the dose used in cardiology, and with the higher doses the PR interval should be checked with an ECG. At the start of a cluster, transitional preventive treatment such as corticosteroids or greater occipital nerve blockade can be given. In CCH and in long-standing clusters of ECH, lithium, methysergide, topiramate, valproic acid and ergotamine tartrate can be used as add-on prophylactic treatment. In drug-resistant CCH, neuromodulation with either occipital nerve stimulation or deep brain stimulation of the hypothalamus is an alternative treatment strategy. For most cluster headache patients there are fairly good treatment options both for acute attacks and for prophylaxis. The big problem is the diagnosis of cluster headache as demonstrated by the diagnostic delay of 7 years. However, the relatively short-lasting attack of pain in one eye with typical associated symptoms should lead the family doctor to suspect cluster headache resulting in a referral to a neurologist or a headache centre with experience in the treatment of cluster headache.

Oral Triptans in the Preventive Management of Cluster Headache

Cluster headache is a rare primary neurovascular headache and a severe pain condition with unilateral headache over 15-180 minutes and concomitant unilateral autonomic symptoms. The detailed pathophysiology of the condition is still unclear. Only a few evidence-based therapeutic options for acute therapy and the preventive management of the disease are available. Triptans, in particular sumatriptan 6mg subcutaneously, are highly effective for acute treatment. This review focuses on the potential use of oral triptans in the prophylaxis of cluster headache.