March 06, 2009
Tribune Media Services
DEAR MAYO CLINIC: I have been suffering from what's been diagnosed as cluster headaches for several years. I never know when I'll be getting one, and the medication I've been given is only to be taken when I feel the headache coming on. Is there any new information about cluster headaches? Specifically, is there any new medication or new research?
ANSWER: You have many medication options to prevent and treat cluster headaches. When medications don't work, other treatments may help curtail these excruciatingly painful headaches.
The first step is to confirm you are having cluster headaches, which typically occur during what's called a cluster period. This period can last weeks to months and is followed by a remission that may last months or years. While in a cluster period, many patients -- but not all -- know when an attack is likely to begin.
Diagnosing a headache disorder isn't always straightforward. Some of my patients come with a previous diagnosis of cluster headache, when, in fact, it's migraine headache or another headache disorder. Conditions that may cause cluster-like headaches need to be ruled out, too; for example, intracranial tumors, sinusitis and cerebrovascular disease.
If cluster headache is the correct diagnosis, preventing the headaches is the priority. Preventives should be considered when headache attacks are frequent, severe, begin rapidly and are too short-lived for abortive treatment to provide benefit or when abortives don't work.
For short-term prevention, I typically prescribe an 18-day course of prednisone, an inflammation-suppressing drug. It acts quickly in most patients and is the most effective intervention to break the cluster period, inducing remission. Because of potential adverse effects, long-term use is not recommended.
For longer-term prevention, verapamil helps maintain remission. Most people can take it safely for longer periods. Other less commonly used medications are lithium carbonate, topiramate and divalproex sodium.
Preventive treatment is best started early in the cluster period and should continue until you are headache-free for several weeks. The maintenance preventive can then be tapered off. Therapy should restart when the next cluster period begins.
To treat an individual cluster headache, breathing pure oxygen at a rate of 7 to 10 liters a minute for 15 to 20 minutes provides dramatic relief for many patients. But this therapy is not very practical if a headache starts when you're away from home. Unfortunately, for some patients, oxygen merely delays an attack and isn't a good option.
A portable alternative is an injection of sumatriptan (Imitrex), a medication also used to treat migraine headaches. Your pharmacy dispenses this drug in cartridges for self-injection. Oxygen and injected sumatriptan are the treatments of choice to stop a cluster headache.
A minority of those who have cluster headaches don't respond to treatment with medication. Here's where newer surgical therapies can be appropriate. One is deep brain stimulation, which can significantly reduce the frequency of headaches for some patients.
In this procedure, a wire lead is surgically implanted in the hypothalamus, the area of the brain that controls sleep and the body's biological clock. These systems are believed to be involved in the genesis of cluster headaches. The lead is connected to an implanted pacemaker-like device programmed to send electrical pulses that prevent cluster attacks from occurring.
A newer procedure uses a similar approach to stimulate the occipital nerve or nerves in the back of the scalp. Invasive brain surgery is not required, and this procedure is likely a next step when medications aren't helpful, even before considering deep brain stimulation. How occipital nerve stimulation works precisely is not entirely understood; it's an active area of research. Some patients benefit greatly from occipital nerve stimulation. Others get moderate, mild or no benefit at all. For about half of patients, headache frequency decreases by at least 50 percent.
Deep brain stimulation or occipital nerve stimulation should be considered only when all medical options have been exhausted and should only be done at a medical center with expertise in performing the procedures.
Given the many choices you have, I'd recommend you consult a physician with headache expertise or a neurologist to confirm your diagnosis and develop a plan to reduce and manage your headaches. -- Ivan Garza, M.D., Neurology, Mayo Clinic, Rochester, Minn.
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