Gulf Coast Pain Management
Benign Pain

 
A Focused Approach to the Management of Cluster Headaches 

A physician cannot diagnose or treat cluster headaches without examining the panoply of headache
potentials.  Cluster headaches affect men six times more frequently than women. The first attack generally
strikes during their twenties or thirties. Cluster headaches produce excruciating pain, usually behind one eye
and can often awake an individual when sleeping. Unlike migraine headaches, cluster headaches do not
appear to be familial. Individual headaches last 15 minutes to 3 hours but these headaches “cluster” and may
occur several times a day for periods of 3 to 16 weeks. The headaches may resolve for months and then
reappear unexpectedly. Occasionally, they become chronic. There appear to be seasonal variations with
spring  or autumn often precipitating a cluster cycle.
 
Diagnosing a cluster headache, or any headache, should be done progressively.
 
As a first step, the physician should ask a series of questions to rule out red-flag headaches, which require urgent
evaluation, preferably by a neurologist or a neurosurgeon.

RED FLAG HEADACHES
The answers to the following key questions can help the physician identify headaches caused by dangerous
underlying conditions:

 1.    Is this the patient’s first headache?

First headaches require special consideration. If a careful history and thorough examination show no
significant findings, reevaluate the patient in three to six weeks to check for subtle, evolving changes.

2.    Did the headaches begin precipitously?

Any headache with an abrupt onset is ominous.  The primary concern is subarachnoid hemorrhage, which
usually results from a ruptured cerebral aneurysm.  Sometimes a cerebral aneurysm will leak before rupturing,
causing a ‘sentinel” headache that begins suddenly and is often accompanied by neck stiffness.
Intraparenchymal brain hemorrhages also present with severe a headache, usually accompanied by focal
neurologic deficit and alteration of consciousness. Epidural hematomas and, rarely, subdural hematomas may
cause headaches many months after head trauma.

3.   Was there significant neck pain with the onset of the headache?

Neck pain with a headache can indicate a hemorrhage in the central nervous system, especially subarachnoid
hemorrhage or stroke.  If focal motor or sensory signs, dysphasia, or cranial nerve abnormalities are present,
the cause may be dissection of the carotid or vertebral arteries.  Neck pain with fever may indicate meningitis.
Cerebellar tumors can cause stiff neck, vomiting, gait ataxia, or dyscoordination. Cervicogenic headaches
caused by referred pain from orthopedic conditions of the neck, usually present with antecedent trauma,
strain, or radicular symptoms.
 
4.   Is the patient complaining of other symptoms, such as fever, vomiting,
or change in the level of consciousness?

A headache accompanied by fever suggests an infectious etiology, such as bacterial or viral meningitis,
encephalitis, or empyema.  Other possibilities of infectious etiology include Lyme disease. A change in the
level of consciousness suggests intracerebral hemorrhage, stroke, or brain tumor.

5.   Have the headaches changed significantly?
 
When the patient indicates that the headache differs from prior headaches in pattern, frequency, duration,
severity, or accompanying symptoms, risk of serious underlying pathologic process increases.  In such cases,
where other corroborative symptoms are present, an urgent neurologic evaluation may be warranted.
 
6.   Is the patient taking any anticoagulant medications?

If the answer is, yes, an emergency assessment and CT scan of the brain are needed to exclude a subdural or epidural hematoma or an intracranial hemorrhage, together with appropriate serological assay.  Any evidence of bleeding requires reversal of the hypercoagulable state, as well as immediate neurologic and neurosurgical consultations.

7.   Is the patient over 55?

The risk of serious underlying neurologic conditions increases significantly with age. Almost all migraine and
tension headaches typically develop before the age of 55, so first headaches in older patients may indicate
vascular or neoplastic causes HEADACHE PATTERN.

 Once red-flag headaches are excluded, the next diagnostic step is to identify the pattern of the headaches. 
Many patients have experienced more than one type of headache without realizing it.  Migraine and tension-type headaches have highly variable occurrence rates. Some patients have them only a few times per year,
while others report occurrences monthly, weekly, or almost every day.  Cluster headaches occur in bunches,
typically striking regularly for a brief period, then disappearing entirely for several months or longer.
 
Knowing the various characteristics of each headache will aid the diagnostic process greatly.
 
Cluster headaches are highly stereotypical, with consistent localization, pain severity, and associated
symptoms.  Even the time of day or season and duration of the cluster bout are highly consistent and
predictable. Individuals with cluster headaches almost always pace the floor during an attack, while migraine
patients prefer to remain still.  Characteristically, those who suffer cluster headaches have epiphora (tearing)
of the ipsilateral eye with conjunctival injection and ipsilateral coryza.  Cluster headaches may awaken
patients with a sudden pain.  If steamy or cloudy vision is a complaint associated with the headache, it is
important to rule out glaucoma.
 
It is important to distinguish between various pain patterns. Migraine headaches typically begin unilaterally,
but bilateral onset does not exclude the diagnosis. Diffuse pain is characteristic of tension headaches.  Pain
that consistently occurs on one side of the head should prompt consideration of structural lesions, such as
arteriovenous malformations, aneurysms, or neoplasms.

Cluster headaches are an exception to this rule.  These headaches cause severe pain localized to one side of
the head, often centered on the eye.  Their cyclic pattern makes them easily recognizable. Persistent occipital
or occipital-nuchal headaches suggest the need for examination of cervical-spine structure and function;
spondylosis and degenerative arthritis often cause occipital and nuchal headaches, especially in older patients.

Migraine headache sufferers report provocation with:
Stress
Foods such as chocolate, sharp cheeses, alcohol, monosodium glutamate,
nitrites used in preserved meats
Skipping meals
Sleep deprivation
Strong odors, especially cigarette smoke
 
Significant provocative factors for cluster headaches are:
Alcohol
Cold wind or heat blown onto face
Less commonly-stress or skipping meals
Cluster headaches are not preceded by auras
 
Tension type headaches are provoked by:
Stress
Exposure to environmental triggers such as loud noise, heat, or bright lights
 
Cluster headaches are not preceded by auras.
 
Migraine headaches are exacerbated by:
Movement
Light
Noise
Odors
Food
Stress
Valsalva maneuvers
 
Cluster headaches are exacerbated by:
Noise
Light
Talking
Chewing
Alcohol both triggers and aggravates these headaches
 
Tension-type headaches are exacerbated by:
Stress
Excessive light and noise
 
Each type of headache has various characteristics.  A very detailed history
is of primary importance when trying to classify a headache. Improper classification
of a headache can result in inappropriate treatment, leading to the development of
chronic daily headaches, which are a nightmare for both the patient and the doctor.
 
The medical and neurologic histories form the basis of treatment for the patient with a
headache disorder.  After completing the history, the physician should know what type
of headache the patient has, whether the problem is acute or chronic, and which tests
to obtain. A thorough neurologic examination both confirms the diagnosis based upon
the history and excludes life- threatening processes.

TESTING

The need for laboratory tests and imaging studies depends entirely on the history
and physical examination.

To Scan or Not to Scan

When to scan
FIRST AND WORST
Worst headache ever experienced
New onset of recurrent headaches
Change in headache pattern
Progressive headache syndrome
Onset with valsalva or intercourse
Papilledema
Abnormal neurological examination
New headache over the age of 50

 When not to scan
A scan may not be indicated when all of the following apply
 History of similar headaches
Normal vital signs and normal general examination
Normal alertness and cognition
Supple neck
Normal neurological examination
Improvement in headache without analgesics or abortive medications

CT Versus MRI Scan
CT scan is preferred for the acute evaluation of the “worst headache ever”
CT is more sensitive to bleeding within the first 24 hours
MRI is the scan of choice for all other headaches

TREATMENT

Each type of headache tends to respond to different medications and nonpharmacologic
treatment.  Acute cluster headaches often respond to high flow 100 percent oxygen within
10-15 minutes of administration.  Other effective treatments include medical treatment with
serotonergic agents and corticosteroids.  Ergotamines are beginning to fall out of favor due
to the risks involved with the medications and the development of newer and more effective
treatments. Narcotics are usually not beneficial in the treatment of cluster headaches.Various
nerve blocks have been found to be very useful; these include: sphenopalatine ganglion blocks,
occipital nerve blocks, and trigger point injections.  Botulinum toxin is being studied as a
treatment for cluster headaches, with promising results.Preventative Medications include:
Verapamil, Lithium, Methysergide, Ergotamine, Prednisone, and Depakote. Alternative
treatments for cluster headaches include biofeedback, relaxation techniques, behavioral
therapy, cognitive restructuring, electrotherapy, acupuncture, physical therapy, and
massage. Patients should be educated to try to avoid alcohol, nitroglycerine, and
precipitating foods, maintain routine sleep patterns, moderate physical activity, control
emotional responsiveness, avoid smoking, and avoid narcotics.

The patient’s past and present use of prescription and over the counter medications
is vital information in the assessment and treatment. The physician should make every effort
to obtain a detailed list of the patient’s over the counter medications in particular. Getting this
information may take close questioning since most patients do not consider aspirin,
acetaminophen, and sinus and allergy preparations to be drugs. The actual dose and
frequency of dosing are also very important.

Patients who ingest large quantities of over the counter drugs or prescription
pain medications often develop chronic headaches. Caffeine and acetaminophen
are the most common causes of substance-related headaches. As the medication’s efficacy
wanes, the patient takes additional pills and eventually develops a chronic cycle of rebound
pain, followed by pill taking-hence the term “rebound headache.” The rebound effect
is also to blame for “transformed migraine,” in which intermittent migraine headaches
begin to occur on a daily or near daily basis, often without any specific trigger. When this
happens, it is necessary to wean patients off of all analgesics before starting prophylactic
treatment.  While the patient is taking high doses of all analgesics, no prophylactic
medication is likely to be effective.  The only successful treatment will take place when
the physician and patient are able to start from a “clean slate”. In instances involving
substance-related headaches, the physician must convince the patient that there is a
relationship between excessive medication or substance usage and headaches and then
devise a tapering schedule.  It is very helpful to have the patient maintain a headache diary
and allow them to be actively involved in the weaning process.  Various nerve blocks
can be helpful during this process. Sphenopalatine ganglion blocks, trigger point injections,
and occipital nerve blocks decrease the intensity and muscle tension associated with
rebound and withdrawal headaches. This in turn makes the weaning process more
bearable and successful. Counseling may also help patients through this process.

For More Information Click Here:
SPHENOPALATINE GANGLION BLOCK ILLUSTRATION

For More Information Click Here:
OCCIPITAL NERVE BLOCK ILLUSTRATION

For More Information Click Here:
TRIGGER POINT INJECTION ILLUSTRATION

Common misdiagnoses include:
Psychological disorder
Eye disease
Sinusitis/Allergy
TMJ/TMD

Overall, a systematic and focused approach to headache diagnosis enables the
physician to offer effective treatment and allows the patient to manage the headache
rather than let the headache manage them.