The autonomic symptoms associated with cluster headache lacrimation, miosis, sweating are thought to be due to parasympathetic outflow from the superior salivatory nucleus via the pterygopalatine sphenopalatine ganglion. Headache disorders can be differentiated by type based on specific characteristics.
Migraine is an episodic headache that lasts between 4 to 72 hours and fulfills the criteria established by the ICHD as shown in Table 1. Most patients with migraine do not have an aura, but when an aura occurs, it is defined as migraine with aura. This is typically a fortification spectra: zigzag lines that move across the visual field. These last from 5 to 60 minutes and are followed by the headache. On occasion, these occur without headache.
Sensory disturbances are the second most common aura pins and needles sensation, numbness usually affecting the face and arm. Language disturbance aphasia is unusual as is motor weakness. When motor weakness occurs, it is classified as hemiplegic migraine. When vertigo, ataxia, diplopia or other brain stem symptoms occur, it is classified as migraine with brainstem aura.
Other prodromal symptoms such as yawning, irritability, neck pain, food cravings, burst of energy, or fatigue may occur hours to days preceding the migraine. Tension-type headache is best described as a mild to moderate, featureless headache. These are attacks of severe unilateral pain, occurring in and around the eye or temple and are associated with ipsilateral conjunctival injection, lacrimation, unilateral sweating, ptosis, or miosis see Table 1 for ICHD definition. Attacks last 15 to minutes, and may occur once every other day to 8 times a day.
Patients are restless or agitated, and may pace or rock to try and relieve the pain. Pain often occurs 1. Attacks often occur in patterns: spring and fall, around the time of the equinoxes.
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This is thought to be related to circadian rhythm. Alcohol is a potent trigger of the headache when a patient is in a cluster headache cycle. It does not trigger an attack outside of a cluster cycle. The steps to headache diagnosis are presented in Figure 2. The first step is to always exclude a secondary headache.
Excluding a secondary headache may require a laboratory evaluation or imaging or both. O : Onset First and the worst headache of life. Headache that reaches pick intensity within seconds to minutes. O : Older age New onset of headache in someone after the age of In general, primary headache disorders begin in young people. P : Progression of an existing headache disorder Change in location, quality, or frequency of the headache.
The most common cause of this is medication overuse. Educating the patient on migraine and its management is crucial for effective treatment.
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Treatment is usually a combination of general preventative measures, prophylactic treatment, and abortive treatment Figure 3. General preventative measures include maintaining a headache diary to identify and avoid triggers, limiting use of acute treatments over-the-counter medications, triptans, etc. Goals for abortive treatment of acute migraine were published in by the US Headache Consortium and include Rapid onset of treatment that works consistently without recurrence; Restoration of normal function with reduced disability; Minimizing use of rescue medication; Optimizing self—care so that there is a reduction in healthcare utilization; Low cost; Minimal adverse effects.
Whenever possible use migraine-specific medications such as triptans or dihydroergotamine. Contraindications are uncontrolled hypertension, cardiovascular and cerebrovascular disease. Use a formulation based on migraine characteristics: nasal spray or subcutaneous formulation in someone with rapid onset headache or who has nausea and vomiting from the onset. Avoid opioids and butalbital containing compounds since these are not only addictive, but rapidly cause medication overuse headache MOH.
Do not use abortive medications more than 10 days per month to avoid MOH. The following are the currently available triptan formulations.
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There are several reasons to consider daily medication to prevent migraines should. Certain uncommon migraine conditions, such as hemiplegic migraine, always require preventative treatment. A clinic-based study on the development of chronic daily headache CDH over the course of 1 year showed that the risk of developing chronic daily headache increased dramatically with the frequency of migraine. The odds ratios for developing CHD was 6. Always start with a low dose of medication and increase gradually to minimize side effects. An adequate trial duration of therapy is 6 to 8 weeks at the target dose.
Encourage patients to use a calendar to accurately assess treatment benefits and evaluate efficacy. Taper the medication and discontinue it if headaches are well controlled. Instruct women about the need for birth control as many of migraine drugs are contraindicated in pregnancy. One medication may be able to be used to treat concurrent disorders Table 2.
Selection of a migraine preventative drug for use should be based on clinical evidence. The American Academy of Neurology recommends evidence-based treatment for episodic migraine. Level A Anticonvulsants: divalproex sodium a , sodium valproate, topiramate a Beta blockers: propranolol a , metoprolol, timolol a Angiotensin II receptor blockers: candesartan Calcitonin gene-related peptide receptor antagonist monoclonal antibody: erenumab-aooe a Natural Supplements: petasites use with caution due to liver toxicity.
The only medication specifically developed for the treatment of migraine is erenumab-aooe Aimovig. Currently, there are 3 additional drugs targeting the calcitonin gene-related peptide receptor in phase 3 clinical trials fremanezumab, NCT; galcanezumab NCT; eptinezumab. Management of tension-type headache begins by identifying and managing possible triggers and comorbid conditions.
Analgesics such as acetaminophen and NSAIDs are usually considered to be first-line treatment for acute tension headache episodes. Combination analgesics, which combine caffeine with first-line drugs should be used as an option if analgesics alone are inadequate.
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Avoid use of barbiturate and opioid medications due to abuse potential and risk of MOH. Always limit use of medication to no more than 2 days a week or 10 days a month to avoid MOH. If tension headache occurs more frequently, prophylactic medication or alternative management strategies such as cognitive behavioral therapy, physical therapy, or acupuncture may be employed.
In general starting with a low dose of medicine and slowly titrating to an effective dose is the best strategy for success. Always use the smallest dose of medication necessary to prevent the headache. Tricyclic antidepressants, such as amitriptyline or nortriptyline, are first-line therapy.
Serotonin and norepinephrine reuptake inhibitors, such as venlafaxine, may be used as an alternative therapy. The main goals for management of cluster headache are to resolve the attack quickly and induce rapid remission of the episode. Management is always done concurrently with both abortive and preventative medications. Rapid control of a cluster headache cycle with a bridge between abortive and preventative medications can be done in a number of ways.
Occipital nerve blocks involve the injection of a steroid with local anesthetic into the occipital nerves.
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Greater occipital nerve block is done ipsilateral to the attack using either betamethasone or triamcinolone with bupivacaine 0. High-dose systemic steroids can be given over a course of 10 days to 2 weeks. Either prednisone 60 mg to 80 mg or dexamethasone should be used. A Medrol dose pack does not provide a high enough dose or a long enough duration to be of benefit. Dihydroergotamine using a modified Raskin protocol 21 can be done on an outpatient basis.
The patient can be taught how to give a self-injection or the use of nasal spray to administer 1 mg every 8 hours for 3 to 5 days. The oral agents work too slowly to be of benefit to abort a cluster headache. Preventive treatment for cluster headache is with verapamil 80 mg 3 times daily to mg 3 times daily. Higher doses may be necessary and an electrocardiogram should be done prior to dose escalation above mg per day because of QTC prolongation. The addition of valproate or topiramate to verapamil is sometimes necessary.
For chronic cluster headache, lithium is also used. Thyroid function should be monitored for patients taking lithium. The important components of headache management include: Accurate diagnosis Patient education Nonpharmacotherapy, including trigger management, lifestyle modification diet and exercise , and behavioral therapy Avoid overuse of acute medications: limit to no more than 2 days a week or 10 days a month to prevent medication overuse headache Use of both prophylactic and abortive medications Headache diary, disability or the migraine-specific quality of life questionnaire to monitor response to treatment.
Headache Jennifer S.