Cluster Headache

Aka: Cluster Headache, Trigeminal Autonomic Cephalalgia, Suicide Headache

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II. Epidemiology

  1. Uncommon Headache type
    1. Contrast with the much more common Primary Headaches (i.e. Migraine Headache, Tension Headache)
    2. Prevalence of episodic Cluster Headache
      1. Lifetime: 124 per 100,000 (~1 in 1000)
      2. One year: 53 per 100,000
  2. Much more common in men
    1. Episodic Cluster Headache: 4 to 1 male to female ratio
    2. Chronic Cluster Headache: 15 to 1 male to female ratio
  3. Age of onset
    1. Rare in children under age 10 years old
    2. Male: 20 to 40 years old
    3. Female: Onset peaks in 60s (especially in black women)
  4. Hereditary
    1. Autosomal Dominant inheritance pattern in 5% of Cluster Headache patients
    2. First degree relative with Cluster Headache confers 5 to 18 fold increase in Cluster Headache risk
    3. Associated with the HCRTR2 gene

III. Pathophysiology

  1. Trigeminal autonomic Cephalgia
  2. Migraine Variant
  3. Postulated mechanisms
    1. Vascular dilation
    2. Trigeminal Nerve stimulation
    3. Circadian rhythm association (onset of Cluster Headaches often occurs during sleep)

IV. Types: Trigeminal Autonomic Cephalalgia

  1. Cluster Headache (most common)
    1. Severe unilateral Headaches (orbital, supraorbital or temporal) lasting up to 3 hours, as often as 8 times daily
      1. See Diagnosis below
    2. Episodic (90%)
      1. At least 2 cluster periods each lasting one week or more (but less than one year)
      2. Remission periods last >3 months
    3. Chronic (10%)
      1. Headaches occur for more than one year
      2. Remissions last <3 months
  2. Cluster Headache Variants
    1. Short-Lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection or Tearing (SUNCT Headache)
      1. Very brief (<4 minute) recurrent cluster-like Headaches
    2. Paroxysmal Hemicrania
      1. Brief cluster-like Headaches <30 minutes relieved with Indomethacin
    3. Hemicrania Continua
      1. Continuous cluster-like Headache relieved with Indomethacin

V. Risk Factors

  1. Tobacco Abuse
  2. Family History of Headache (esp. first degree relative with Cluster Headache)
  3. Head Injury
  4. Shift work
  5. See triggers below

VI. Symptoms: Cluster Headache

  1. Characteristics
    1. Deep pain
    2. Burning, stabbing, or lancinating type pain
  2. Severity
    1. Excruciating pain
    2. Patient may even consider Suicide (hence the common name, "Suicide Headache")
  3. Location
    1. Unilateral Headache typically behind one eye
    2. May be orbital, supraorbital or temporal pain
    3. Radiates to upper teeth, jaw or neck
  4. Timing
    1. At least 5 attacks within 10 days
    2. Occurs from every other day to as often as multiple daily episodes up to 8 per day
    3. Headaches last 15 to 180 minutes
    4. Usually recur at same time of day each day
    5. May awaken patient from sleep (esp. onset of REM)
    6. Recurrence over >1 year without remission of >1 month
      1. However, in those meeting initial criteria for Cluster Headaches, later remissions may last for months to years
  5. Triggers
    1. Sleep Apnea
    2. Food containing nitrates
    3. Nail varnisn
    4. Petroleum
    5. Vasodilators
      1. Nitroglycerin
      2. Alcohol
      3. Histamine
  6. Associated with at least one of the following
    1. Lacrimation
    2. Ipsilateral forehead or facial Flushing or sweating
    3. Ipsilateral Nasal Discharge
    4. Affected eye red with dilated Conjunctival vessels (Conjunctival injection)
    5. Restlessness, pacing or rocking head in hands
    6. Horner's Syndrome (30% of cases)
      1. Ipsilateral Ptosis
      2. Ipsilateral pupillary constriction (Miosis)

VII. Evaluation

  1. See Headache Evaluation

VIII. Imaging

  1. Routine head imaging is no longer recommended
    1. Previously MRI Brain with and without contrast was recommended in all Trigeminal Autonomic Cephalalgia
  2. Indications for head imaging (Head CT or Brain MRI)
    1. See Headache Red Flags
    2. Sudden changes in Headache features
    3. Signs of infection
    4. Focal neurologic findings (e.g. weakness, Double Vision or Vision Loss, mental status changes)

IX. Diagnosis : Cluster Headache

  1. Characteristics: Five or more Headaches meeting the following criteria
    1. Severe to very severe unilateral orbital, supraorbital or temporal pain lasting 15-180 minutes if untreated
    2. Headaches occur from every other day to eight times daily
    3. Headache with at least one of the following ipsilateral autonomic symptoms
      1. Conjunctival injection or Lacrimation
      2. Nasal congestion or Rhinorrhea
      3. Eyelid Edema
      4. Forehead and facial sweating
      5. Miosis and or Ptosis
      6. Restlessness or Agitation
  2. Timing
    1. Episodic Cluster Headache
      1. Two or more cluster periods lasting 7-365 days and separated by pain-free remissions >3 months
    2. Chronic Cluster Headache
      1. Episodes recur for more than 1 year without remission or with remission <3 months
  3. References
    1. (2018) Cephalgia 38(1):1-211 [PubMed]

X. Differential Diagnosis

  1. Migraine Headache
    1. Common Migraine features do not distinguish from Cluster Headache
      1. Aura occurs in 14% of Cluster Headaches
      2. Photophobia occurs in >50% of Cluster Headaches
    2. Migraine Headaches are worsened with movement
      1. Contrast with Cluster Headaches in which patients are restless and agitated
  2. Hemicrania Continua (or Paroxysmal Hemicrania)
    1. Cluster-type Headache with brief duration (2-30 minutes)
    2. More common in women ages 30-40 years old
    3. Responds well to Indomethacin
  3. Brief Neuralgiform Headache with Conjunctivitis
    1. Unilateral Headache with Conjunctival injection and tearing
    2. Episodes last <4 minutes with recurrence from 3 to 200 times daily
    3. More common in men ages 35 to 65 years old
    4. Refractory to most Headache treatment strategies
  4. Brief Neuralgiform Headache with cranial autonomic symptoms
  5. Orbital Myositis
    1. Similar to Cluster Headache with longer duration
  6. Tension Headache
  7. Trigeminal Neuralgia
    1. Typically affects second and third branches of the Trigeminal Nerve (V2, V3)
    2. In contrast when the first branch (V1) is affected, findings are consistent with Cluster Headache
  8. Intracranial Mass (e.g. Pituitary Adenoma)

XI. Management: Nonpharmacologic measures

  1. Relaxation Techniques
  2. Cognitive-behavior therapy
  3. Treat comorbid Mood Disorders
  4. Tobacco Cessation
  5. Alcohol cessation

XII. Management: Abortive Treatment for Acute Cluster Headache

  1. See Migraine Treatment
  2. First line agents
    1. Oxygen Inhalation
      1. Apply 100% via nonrebreather Face Mask at 12-15 Liters per minute for 15-20 minutes
      2. Complete relief in 78% of patients
        1. Cohen (2009) JAMA 302(22): 2451-7 [PubMed]
      3. Home use is often covered by private insurance but not by Medicare and medicaid
    2. Triptan Agents
      1. See Triptans for adverse effects and contraindications
      2. Sumatriptan (Imitrex)
        1. Intranasal 20 mg (may repeat once in 24 hours)
          1. Slower onset than subcutaneous Sumatriptan
        2. Subcutaneous: 6 mg SC (may repeat once after 1 hour)
          1. Significant pain relief with 6 mg dose in 75% of patients by 15 minutes (NNT 2.4)
          2. Higher dose (12 mg) adds adverse effects without additional benefit
      3. Zolmitriptan
        1. Intranasal 10 mg (two sprays of the 5 mg Inhaler)
          1. Significant pain relief in 63% of patients by 30 minutes (NNT 2.8)
        2. Oral: 5 mg orally (may repeat once in 24 hours)
          1. Second line option limited to acute episodic Cluster Headache
  3. Agents with weaker evidence
    1. Intranasal Lidocaine 4-10% solution
      1. Dose: 1 ml intranasally
        1. Lidocaine 10% applied with cotton swab bilaterally for 5 minutes
      2. May be repeated twice in 15 minutes prn
      3. Relieves pain within 5-15 minutes
      4. Costa (2000) Cephalalgia 20:85-91 [PubMed]
    2. Indomethacin
      1. Dose: 25-50 mg three times daily prn
      2. Effective in Hemicrania Continua (or Paroxysmal Hemicrania)
      3. May have delayed benefit
      4. May be reasonable to administer with other management to improve sustained relief
    3. Octreotide (Sandostatin)
      1. 100 mcg/ml SC decreases Headache severity
      2. Matharu (2004) Ann Neurol 56(4): 488-94 [PubMed]
    4. Intranasal Dihydroergotamine 0.5 mg bilateral nares
      1. Reduces Headache severity
      2. Does not decrease cluster frequency or duration
      3. Andersson (1986) Cephalalgia 6:51-4 [PubMed]
    5. Intranasal Capsaicin
      1. Applied to ipsilateral nostril bid for 7 days
      2. Marks (1993) Cephalalgia 13:114-6 [PubMed]

XIII. Management: Transitional from Abortive to Prophylaxis

  1. Suboccipital Corticosteroid Injection
    1. See Occipital Nerve Block
    2. Ambrosini (2005) Pain 118(1-2): 92-6 [PubMed]
    3. Leroux (2011) Lancet Neurol 10(10): 891-7 [PubMed]
  2. Corticosteroids
    1. Consider as Bridging Therapy from acute cluster Headache Management to prophylaxis
    2. Prednisone 50 mg for 1-3 days and then tapering over 10-14 days

XIV. Management: Prophylaxis for Cluster Headaches

  1. See Migraine Prophylaxis
  2. Verapamil
    1. First-line agent for prophylaxis (best evidence)
    2. Obtain baseline EKG
    3. Dosing
      1. Minimum effective dose is 240 mg (as a single dose or in divided doses)
      2. Start: 80 mg orally three times daily (or XR at 240 mg orally once daily)
      3. Titrate: Increase to 120 to 160 mg orally three times daily (or up to XR at 480 mg orally once daily)
  3. Second-line agents when Verapamil is ineffective or contraindicated
    1. Melatonin 10 mg orally daily
    2. Nasal Civamide 50 mcg (not available in U.S.)
    3. Lithium
      1. Dose: 300-600 mg/day initially (Maximum 900 mg/day)
      2. Base dose on serum Lithium levels
      3. Requires careful monitoring (Lithium level, TSH, Renal Function)
    4. Galcanezumab (Emgality)
      1. CGRP Antagonist FDA approved for Cluster Headaches
      2. Consider if refractory to other measures (very expensive)
      3. In study was administered monthly for 3 months
        1. Goadsby (2019) N Engl J Med 381(2): 132-41 [PubMed]
  4. Refractory management
    1. Sphenopalatine Ganglion stimulation
      1. Shoenen (2013) Cephalgia 33(10): 816-30 [PubMed]
    2. Gamma Knife Radiotherapy
      1. Kano (2011) J Neurosurg 114(6): 1736-43 [PubMed]
    3. Noninvasive Vagal Nerve Stimulation (FDA approved)
      1. Silberstein (2016) Headache 56(8): 1317-32 [PubMed]
      2. Goadsby (2018) Cephalgia 38(5): 959-69 [PubMed]
      3. Gaul (2017) J Headache Pain 18(1): 22 [PubMed]
  5. Other agents (variable efficacy)
    1. Indomethacin 25-50 mg three times daily
    2. Anticonvulsants
      1. Topiramate (Topamax)
      2. Gabapentin (Neurontin)
  6. Avoid agents not recommended due to lack of efficacy or with serious adverse effects
    1. Valproic Acid
      1. Does not appear effective in Cluster Headaches
    2. Methylsergide
      1. No longer recommended due to systemic fibrosis

XV. References

  1. Beck (2005) Am Fam Physician 71:717-28 [PubMed]
  2. Dalessio (2001) Postgrad Med 109(1):69-78 [PubMed]
  3. Dodick (2000) Cephalalgia 20(9): 787-803 [PubMed]
  4. Francis (2010) Neurology 75(5): 463-73 [PubMed]
  5. Hainer (2013) Am Fam Physician 87(10): 682-7 [PubMed]
  6. Malu (2022) Am Fam Physician 105(1): 24-32 [PubMed]
  7. Weaver-Agostoni (2013) Am Fam Physician 88(2):122-128 [PubMed]
  8. Zakrzewska (2001) Br J Oral Maxillofac Surg 39:103-13 [PubMed]

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