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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.
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SPHENOPALATINE GANGLION BLOCK ILLUSTRATION
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OCCIPITAL NERVE BLOCK ILLUSTRATION
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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.

Fire Lieutenant/Paramedic Allen Krauza
credits Dr. Columbus for helping him get
his life back to normal.
Read the article Click Here
If you have any questions whatsoever regarding
whether or not it may be helpful for your headaches,
please do not hesitate to ask Dr.
Columbus
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Botulinim Injections For Headaches
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