Makindo Medical Notes.com

Related Subjects:Migraine |Basilar Migraine |Cluster Headaches |Sumatriptan |Tension Headache |Analgesic Overuse Headache |Headaches in General

About

• Severe episodic headaches in older patients that occur "in clusters" for several weeks and months
• They then resolve for a period and then return at a later point in another cluster

Aetiology

• Possibly neuropathic

Clinical

• Severe short-lasting headaches over a period of days and weeks
• More commonly seen in men. Usual pain around one eye and face
• Associated eye-watering. Even swelling and redness of the eyelid.
• Miosis and conjunctival injection. Temporal artery pulsation.

Consider diagnosis

• The person has had at least five attacks of severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes and
• The headache is associated with at least one of ipsilateral conjunctival injection and/or lacrimation; nasal congestion and/or rhinorrhoea; eyelid oedema; forehead and facial sweating; forehead and facial flushing; sensation of fullness in the ear; or miosis and/or a sense of restlessness or agitation.
• Attacks occur between one every other day and eight per day for more than half of the time when the disorder is active.

Investigations

• None specific. Exclusion of other causes may be need.
• CT/MRI may be indicated if other diagnoses contemplated e.g. Haemorrhage, SOL

Differential

• Migraine, Orbital disease/Acute red eye
• Carotid dissection, Space occupying lesion, SAH or Meningitis

Acute Management

• Oxygen: Inhalation of 90% oxygen via a non-rebreathing face mask with a flow rate of at least 7L/min (sometimes more than 15 L/min is required). The oxygen should be inhaled for 10-20 minutes. About 60% of all cluster headache patients respond to this treatment with significant pain reduction.
• Non-oral triptans: Sumatriptan subcutaneous (6mg), sumatriptan 20mg intranasal and zolmitriptan 5mg intranasal are effective in the acute treatment of cluster headache. The quantity supplied needs to match usage. There is no evidence supporting the use of oral triptans for cluster headaches.
  • zolmitriptan intranasal 3 doses/24 hours,
  • sumatriptan s/c max 12mg/24 hours,
  • sumatriptan intranasal 10-20mg/dose max 100mg/24 hours.

Prevention

• Verapamil: in a total daily dose of 240-960mg is the first-line choice in the prophylaxis of episodic and chronic cluster headache. Initially, it should be started at a dose of 80mg TDS and titrated upwards usually every 14 days. Modified release formulations can be used to reduce tablet burden and aid compliance. The full efficacy of verapamil can be expected within 2-3 weeks.
• Lithium carbonate: total daily dosage between 600 and 1500mg has been studied in multiple open trials. It is used in both episodic and chronic cluster headache if verapamil is ineffective or contraindicated. Monitoring of the lithium level is required(should be between 0.3 and 1.2mmol/l). Monitoring requirements are in the SCF for lithium carbonate.
• Corticosteroids: may be recommended for short term treatment (2-3 weeks) high dose prednisolone 30mg or greater. The initial dose may be as high as 60-100mg prednisolone for 2-5 days. Prednisolone may be used while titrating other prophylactic drugs to a therapeutic dose.
• Melatonin: As cluster headache is thought to be related to circadian effects melatonin has been tried as prophylaxis with varying results.
• Greater occipital nerve block – Lidocaine with or without corticosteroids can be used in an outpatient setting by specialist teams. It often used instead of oral steroids as a bridging treatment while awaiting preventative medicine such as verapamil to take effect.
• gammaCore: this is an innovative medical device treatment for cluster headache. It is a non-invasive vagus nerve stimulator that enables the patient to ‘zap’ their vagus nerve to reduce pain from cluster attacks. It is NHS England funded and NICE approved. It is prescribed by specialist teams following the failure of first-line prophylactic treatment i.e. verapamil. It can be used as daily prophylaxis and acute treatment.

References

• Migraine management