New - April 2011
MANAGEMENT OF CHRONIC CLUSTER HEADACHE.
Leone M, Franzini A, Proietti Cecchini A, Mea E, Broggi G, Bussone G.
SourcePain Neuromodulation Unit, Department of Neurology, Headache Center, Carlo Besta Neurological Institute Foundation, Via Celoria 11, 20133, Milano, Italy, leone@istituto-besta.it.
OPINION STATEMENT: Primary cluster headache (CH) is an excruciatingly severe pain condition. Several pharmacologic agents are available to treat chronic CH, but few double-blind, randomized clinical trials have been conducted on these agents in recent years, and the quality of the evidence supporting their use is often low, particularly for preventive agents. We recommend sumatriptan or oxygen to abort ongoing headaches; the evidence available to support their use is good (Class I). Ergotamine also appears to be an effective abortive agent, on the basis of experience rather than trials. We consider verapamil and lithium to be first-line preventives for chronic CH, although the trial evidence is at best Class II. Steroids are clearly the most effective and quick-acting preventive agents for chronic CH, but long-term steroid use carries a risk of several severe adverse effects. We therefore recommend steroids only if verapamil, lithium, and other preventive agents are ineffective. In rare cases, patients experience multiple daily cluster headaches for years and are also refractory to all medications. These patients almost always develop severe adverse effects from chronic steroid use. Such patients should be considered for neurostimulation. Occipital nerve stimulation is the newest and least invasive neurostimulation technique and should be tried first; the evidence supporting its use is encouraging. Hypothalamic stimulation is more invasive and can be performed only in specialist neurosurgical centers. Published experience suggests that about 60% of patients with chronic CH obtain long-term benefit with hypothalamic stimulation.
Headache. 1996 Mar;36(3):174-7.
Chronic cluster headache: provocation with carbon dioxide
breathing and nitroglycerin.
Hannerz J, Jogestrand T
Department of Neurology, Karolinska Hospital, Stockholm, Sweden.
Nine patients with chronic cluster headache were studied as to end-tidal PCO2,
heart rate, blood pressure, common carotid artery blood flow, vascular
resistance, and intensity and duration of pain before, during, and after
breathing 6% CO2 in air for 6 minutes and before and after administration of 1
mg nitroglycerin sublingually. End-tidal PCO2 was low at rest without
provocation indicating that chronic cluster headache patients hyperventilate.
Carbon dioxide provocation induced an increase in common carotid artery blood
flow. This provocation, previously shown to induce pain in episodic cluster
headache patients, did not result in unilateral pain in chronic cluster headache
patients. Nitroglycerin did not provoke any pain in 4 of 5 chronic cluster
headache patients in contrast to the effects in episodic cluster headache
patients in a cluster period. In one chronic cluster headache patient, a
short-lasting attack of moderate pain intensity was provoked. The results agree
with the hypothesis that chronic cluster headache patients have changed vascular
reactivity due to permanent sympathicoplegia unilaterally in the middle fossa in
contrast to episodic cluster headache patients who it has been suggested have a
nonpermanent sympathicoplegia unilaterally in the same region.
PMID: 8984091 [PubMed - indexed for MEDLINE]Entrez PubMed
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