Cluster headaches

Cluster headaches are ten times less common than migraines. They touch   men more frequently than women and especially smokers. They usually start at middle or advanced age. It is not uncommon to find other people with headache in the family, in about 7% of cases it is also cluster

The seizures are characteristic: They begin at the level of the temple and the eye, and thus touch a part of the face and the skull. They are invariably and without exception on the same side. The intensity of pain increases rapidly and reaches its peak in 20 minutes. They generally give way completely after 1 to 2 hours. 

It is not uncommon for headaches to occur at the same time during the day and especially at night. But seizures can also occur several times a day. During seizures, the patient is restless and wanders around his room like a tiger in his cage. 

In general, these attacks occur in clusters that last several days or even weeks, before disappearing for a period of several months. However chronic cases, with crises for several months, even years, also exist. Transitional forms with migraines are also described.  

The appearance of the patient during the seizure is characteristic: the affected eye is red and watery, the nose is flowing, the palpebral fissure and the pupil are narrower. 

The origin of seizures is suspected to be hypothalamic dysfunction. A genetic predisposition is likely. 

The treatment of a seizure consists of the subcutaneous injection of 6 mg of sumatriptan, or treatment with tiptan in spry nasal: either sumatriptan 20 or zolmitriptanr 5;   or administering pure oxygen at 12 to 15 liters / minute. The frequency of seizures can be decreased by either verapamil treatment during the period or transiently by prednisone. 

In exceptional cases with refractory seizures, various neurosurgical therapeutic approaches are available in small series of cases of a pain relief effect. For chronic cases, lithium is prescribed.

Oxygen treatment of the headache cluster (cluster headaches) 

Oxygen treatment of the headache cluster (cluster headaches) 
The therapeutic range concerning the treatment of headache cluster seizures is not very wide. The efficacy of fast-acting triptans (injectable or nasal spray) is well known, but not always applicable (contraindications, maximum daily doses recommended according to the Compendium). Tolerance and effectiveness of 100% oxygen inhalations through a face mask (Non-Rebreather mask), 10-12l / min for 15-20 minutes,   has been demonstrated (Cohen AS et al., High-flow oxygen for treatment of cluster headache: a randomized trial, JAMA 2009, Bennett MH et al., Normobaric and hyperbaric oxygen therapy for migraine and cluster headaches, Cochrane Database Syst Rev 2008).

As a survey of members of the Swiss Headache Society has shown, this treatment with oxygen therapy during cluster crises is quite   widely used but not always easy to prescribe, this indication not included in the recommendations for the prescription of oxygen, which otherwise is not always easily provided.

Because of the high cost-benefit ratio (relative to triptans), as well as the good and rapid efficacy of this treatment in approximately 80% of seizures, we recommend that this treatment be taken into consideration.

An example of a prescription for short-term treatment with oxygen therapy is available on our homepage.   The standard regulation   is on   the website   of the pulmonary league.

CGRP Receptor Antagonists (Calcitonin-Gene-Related Polypeptide) in the treatment of migraine attack.

Verschiedene Substanzen ohne vasokonstriktive Eigenschaften befinden sich in der Entwicklung. Dazu gehört die neue Substanzklasse der sogenannten CGRP-Rezeptor-Antagonisten. Das körpereigene Eiweiss CGRP spielt eine wichtige Rolle in der Entstehung der Migräne. Während Migräne- und Clusterkopfschmerzattacken wurden erhöhte Konzentrationen von CGRP im Jugularvenenblut gemessen.  

CGRP-Rezeptor-Antagonisten zeigten Wirksamkeit bei Migräneattacken: In einer randomisierten doppelblinden placebokontrollierten Studie (1) war eine iv-Applikation of CGRP-Antagonisten Olcegepant wirksam.CGRP-Antagonist Telcagepant Oral Derivative Contraindications in Controlling Doppelblinden Contraindications in 300-600mg ähnlich wirksam wie Rizatriptan 10mg und wirksamer als Placebo (2). Aufgrund von Leberwerterhöhungen bei einer geringen Anzahl von Patienten im Studienprogramm wurde die Entwicklung dieser Substanz von der Firma nicht weiterverfolgt. 

In den letzten Jahren wurden nun von verschieden Pharmafirmen neue Antikörper gegen CGRP oder den CGRP-Rezeptor entwickelt. In Phase-II-Studien zeigten alle 4 Antikörper eine bessere Wirksamkeit als Placebo, ohne relevante Nebenwirkungen. Nun gilt es in Phase-III-Studien diese Wirksamkeit zu belegen und insbersondere auch die Langzeitsicherheit zu gewährleisten. Auch Schweizer Zentren haben sich an den internen Studien beteiligt.  

  • ischemic stroke
  • cerebral hemorrhage (subarachnoid haemorrhage, subdural hematoma)
  • arteritis
  • dissection
  • hypertensive encephalopathy

Dangerous headaches 

The first step in the diagnostic approach for a headache patient is to distinguish between the two major categories of headache, primary or idiopathic headache (approximately 80%), the main ones being migraines, tension headaches, and headaches. cluster headache) and secondary or symptomatic headaches (20%). 

The first group is classified according to the clinical symptomatology, the second according to the etiology. The dangerous headaches are found in the group of symptomatic headaches, and constitute the checklist of the “9 famous causes”: 

Table of symptomatic headaches 

1. circulatory disorders 


  • venous thrombosis / venous sinus

2. cerebrospinal fluid circulation disorder

  • hydrocephalus
  • intracranial hypotension

3. infections

  • intracranial: meningitis, brain abscess
  • cranial sinusitis, otitis, pulpitis
  • systemic: pneumonia, pyelonephritis

4. trauma

  • cranio-cerebral trauma
  • epidural hematoma

5. tumors

  • brain tumors
  • metastases

6. toxic

  • pharmaceuticals
  • industrial toxic (nitrous)
  • Ergotamine abuse
  • lead poisoning
  • with carbon monoxide

7. metabolism

  • hypoxia
  • hyperthyroidism
  • hypoglycemia
  • dialysis
  • etc.

8. degenerative condition

  • cervical spondylosis

9. neuralgia

  • symptomatic forms (eg neuroma of the acoustic nerve)

The most frequent and potentially dangerous causes of symptomatic headaches are systemic infections, sinusitis, trauma, intracranial infections, haemorrhage (subarachnoid haemorrhage, subdural hematoma, cerebral haemorrhage) and hydrocephalus. 

Dangerous headaches are less detectable by their intensity or accompanying phenomena (eg vomiting) than by anamnesis, their evolution over time (acute headaches, chronic headaches) and the nature of the associated symptoms (focal neurological abnormality). which will have to be specifically investigated during the history and examination.  
Magnetic resonance imaging (MRI) requires precise indication: meningitis or temporal arteritis are not diagnosed by this examination.

Pain of the face 

The pain of the face has very different origins: it can be headaches particularly affecting the face, such as cluster headaches, but also a migraine with irradiation of pain in the face, a trigeminal neuralgia or persistent idiopathic facial pain. It can also be pain that radiates from the sinuses, teeth, eyes, the temporomandibular joint, or even the cervical spine. 

If your headaches are new, accompanied by swelling and redness in one eye, as well as visual disturbances, this is an inflammatory disease. 

An urgent consultation is essential, in order to start anti-inflammatory treatment as quickly as possible. 

If you suffer from sharp, throbbing pain in the face, invariably affecting the same territory, it is most likely a trigeminal neuralgia. Specific treatment will be necessary because the usual painkillers are ineffective. 

The same is true for cluster headaches, which are characterized by severe, unilateral, periorbital headaches, occurring recurrently, every day. These headaches are accompanied by lacrimation, nasal discharge or obstruction, redness of the eye, ptosis of the eyelid. 

In both cases, a neurological assessment is indicated. 

In the case of mandibular or dental pain, with no obvious cause for dental examination or x-rays, the extraction of healthy teeth will be of no help: 

Idiopathic persistent facial pain and trigeminal neuralgia can perfectly simulate dental pain, and will not respond to tooth extraction.

Who to consult in case of headaches: family doctor or specialist?   

We almost always suffer from headaches, especially in case of illness, fatigue or overwork. 

The majority of these headaches disappear spontaneously or respond to a simple analgesic treatment, using drugs that do not require a medical prescription. 

It is rarely necessary to consult the doctor for this type of headache. 

When is a consultation indicated? In case of   

  • frequent headaches
  • headache not responding to simple pain relievers
  • headaches interfering with daily activities
  • headache presenting characteristics suggestive of a severe cause (see “dangerous headaches”)

Your doctor will, in view of the characteristics of the headaches that you describe (history) and then the careful clinical examination, a diagnosis of the nature of the headache, and will ask for additional examinations if necessary. 

In order to facilitate the work of the family doctor, which is often overloaded, it is useful to list the history of headaches in writing before the first consultation: When did they start? What is their duration and frequency? What is the sequence of events during a crisis? Are there triggers? 

Holding a crisis schedule will be very helpful to your GP. 

If your doctor suspects an underlying disease, he will refer you to a fellow neurologist, who specializes in diseases of the nervous system, who will arrange the necessary additional examinations to rule out a possible severe illness. 

Depending on the suspected pathology, he will suggest you to perform CT or magnetic resonance imaging (MRI). Simple x-rays of the skull are not useful for looking for the origin of headaches. The same is true of electroencephalogram (EEG), which is only indicated if you have unconsciousness in association with headaches. 

Once the diagnosis is made, the doctor will establish with you the therapeutic plan, not medicated such as for example relaxation exercises and behavioral rules, or medications.  

If, despite treatment, your headache should become more severe or more frequent, consultation with a headache specialist should be considered. This is also the case when the use of analgesic or anti-migraine drugs gradually increases, causing suspicion of headaches due to the abuse of drugs.

What does the term “co-morbidity” mean in the context of migraines 

Co-morbidities are medical conditions other than the basic disease, diagnosed alone or with others in a subject. Thus in patients suffering from migraines, there are frequently psychiatric co-morbidities, but also diseases of internal medicine or neurology. The diagnosis of these co-morbidities can have important consequences, especially   for the choice of the drug for the preventive treatment of migraine. 

Migraines are frequently associated with depressive states. Mental depression can be unipolar or bipolar. Drug treatment with tricyclic antidepressants acts on both the depressive state and migraines.  

In subjects with bipolar depression, preventive treatment of migraine with antiepileptic drug such as valproate or topiramate, which also acts as mood stabilizers, may be a wise choice. 

In case of unipolar depression associated with migraines, the choice will be on another anti-epileptic, lamotrigine. 

The simultaneous presence of migraines and epilepsy justifies the choice of anti-epileptic treatment such as valproate or lamotrigine, which also have a beneficial effect on migraines. 
· Given that the Topiramat reduces body weight in obese patients, this formulatio may be preferred for adipose patients with migraine. 

The diagnosis of co-morbidity · will therefore allow an optimal choice of the preventive treatment of migraine.

Good quality of life despite migraines? 

It is   at a time when the quality of life is deteriorating, the majority of people are becoming aware of its value. Migraines can be the cause, when seizures are frequent or when their number increases gradually: The patient realizes that his quality of life has decreased. What does that mean ? 

Migraines affect us directly: the functions of the brain and the body are altered. Pain alters the quality of life up to   what a treatment relieves. The rapid availability of a drug that is effective and long lasting improves the quality of life. You get back to life and can resume your activities.  

Migraines stigmatize us. Although we are usually efficient at work, we are not always effective. Frequent and unpredictable crises   prevent a reliable presence at work and participation in family life. The avoidance of social activities further aggravates the situation. 

Migraines can be a threat to different aspects of our daily life: the professional activity and therefore the salary, the promotion, the relations relations (with the partner, the family, the colleagues), they can alter the blooming , self-esteem, plans for the future, dreams and hopes. Chronic or violent headaches can make us see everything in black. 

Some are deeply discouraged by the occurrence of a severe crisis every few weeks. The use of medication during   8 to 10 days a month, certainly alters the quality of life. In this situation, the indication of a preventive treatment should be discussed with your doctor. 

What are the other possibilities? 
Increase your knowledge of headaches by reading the information on this website. Perhaps you could benefit from coaching: A brief psychotherapy can help you find future prospects.

Many diseases cause headaches 

O. Meienberg / February 2013 

Headaches, whether diffuse or localized in certain parts of the skull, can have many causes. These can be trivial, for example the after-effects of a sleepless night, or on the contrary serious, for example a cerebral hemorrhage. 

In the first case, the cause is obvious and the possible treatment by means of a simple easy analgesic. There is no reason to be worried. 

However, if it is a first episode of headaches, or headaches different from those   that you know, severe headaches or other abnormalities such as fever, vomiting, paresis, etc., a medical consultation is essential to determine the origin. In case of unusual headaches, with rapid aggravation and deterioration of the general condition, emergency hospitalization may be indicated, for example to eliminate meningitis or haemorrhage by rupture of a cerebrovascular malformation. 

The international classification of headache has proven to be a considerable diagnostic aid for the physician. This defines all the important forms of headaches and their causes. 

Three main groups of headaches are thus distinguished:

  • primary headaches (= no other cause), the most important of which are migraines, cluster headaches and tension headaches
  • secondary headaches (= caused by another condition)
  • cranial neuralgia and central and primary pain of the face and other rare headaches

Depending on the type of headache and the suspected cause, the doctor will ask for further tests, such as sedimentation rate or magnetic resonance imaging (MRI).     

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