Cluster headaches, known for their intense pain, are a debilitating condition that primarily affects the eye, temple, and forehead. These headaches are characterized by severe, rapid-onset pain, often accompanied by symptoms like a teary eye, runny nose, and droopy eyelid on the affected side. Unlike migraines, cluster headaches are more common in men, follow a seasonal pattern, and are associated with agitation during attacks. Episodes last from 15 minutes to 3 hours and can occur up to eight times a day. This guide explores the symptoms, differences from migraines, potential triggers, and effective treatments for cluster headaches, offering essential insights for patients and healthcare providers.
What are the typical characteristics of a cluster headache attack?
- Location of pain: Typically around the eye, temple, and forehead. Pain may also radiate to the cheek, jaw, teeth, and neck.
- Type of pain: Very severe and excruciating, sometimes likened to a poker crushing the eye. The pain can escalate rapidly and cease abruptly.
- Other symptoms: On the same side as the pain, symptoms may include a teary eye, runny nose, droopy eyelid, red ear, and a small pupil. Restlessness and agitation are common. Nausea and light sensitivity may accompany the headache.
- Duration of attack: Lasts from 15 minutes to 3 hours, although it may vary and can be shorter with treatment.
- Frequency of attacks: Between one every other day and 8 per day.
For more information, please see the International Headache Society’s classification of cluster headache.
What is chronic cluster headache?
Ninety percent of cluster headache patients experience the episodic form, with periods of remission (i.e., no attacks) lasting more than a month and cluster periods not exceeding a year. Typically, cluster bouts last between 4 to 12 weeks.
Ten percent of patients develop chronic cluster headache, characterized by minimal or no remission periods. These individuals often report a constant baseline pain, shadow pains, and milder attacks. Chronic cluster headache is very difficult to treat and extremely disabling.
Is cluster headache different from migraine?
Cluster headache differs from migraine in several respects:
- It affects more men than women.
- The pain is focused around the eye and temple and is notably more intense and excruciating.
- Symptoms of agitation and restlessness are common.
- Attacks typically last less than 3 hours without acute treatment.
- There is a seasonal pattern with long remissions and predictable, clock-like attacks.
- Oral triptans are less effective compared to migraine treatment.
Similarities between cluster headache and migraine include:
- Both can be triggered by alcohol and vasodilators.
- Triptans (e.g., sprays, injections) are effective in controlling the attack.
- Both conditions may present with a mild degree of autonomic “cluster” symptoms (e.g., teary eye and runny nose) and “migraine” symptoms (e.g., nausea, light and sound sensitivity).
Some individuals experience both types of attacks and can distinguish between them clearly. However, for others, the attacks cannot be easily classified as they exhibit features of both cluster headache and migraine. These individuals are sometimes diagnosed with “cluster migraine,” which is not an officially recognized diagnosis in the international classification but serves as a descriptive term.
Are there triggers for cluster headache attacks?
Typical triggers reported by patients include alcohol consumption, sleep patterns, and neck posture. Drugs like nitroglycerine and Viagra, which dilate blood vessels, may also trigger attacks. However, not all patients report specific triggers.
I have heard that cluster headache is referred to as “suicide headache.” Is this true?
It is unfortunately common for patients with cluster headaches to feel suicidal, especially during an attack. Even between attacks, individuals with cluster headache may have increased suicidal thoughts, and some may even attempt suicide. It is crucial to address these thoughts and provide appropriate support and intervention.
What is the cause of cluster headache?
The cause of cluster headache remains unclear, but several symptoms and characteristics suggest a connection with biological clocks located in the hypothalamus. The attack itself involves the activation of pain pathways of the face. Symptoms such as eye and nose discomfort likely stem from the activation of a normal reflex linking pain networks and other nerves, resulting in tearing, flushing, runny nose, and changes in the eye.
Currently, we do not fully understand why cluster headache can be highly episodic with extended periods of remission, what triggers the onset of a bout, or why some patients progress to the chronic form of the condition.
Is cluster headache genetic?
Evidence supporting a genetic basis for cluster headache is limited. While there are reports of cluster headache occurring in families and among twin pairs, overall, there is not strong evidence of clear genetic patterns. Various genes have been studied, but none have been definitively associated with cluster headache. Currently, most individuals with cluster headache should not be overly concerned about passing it on to their children.
What are the usual treatments for cluster headache attacks?
Cluster headache attacks onset rapidly, necessitating fast-acting treatments.
- Oral triptans are generally too slow unless the attack can be anticipated and the oral triptan is taken in advance.
- Injectable sumatriptan and intranasal zolmitriptan are considered the most effective options for most cluster patients. These medications are not suitable for individuals with a history of heart disease or stroke.
- Inhaled oxygen (100%, 10-15 litres/minute using a non-rebreather mask) is a safe and effective option. However, some patients find that its efficacy is limited, and it may only delay the attack.
- NSAIDs are typically not effective for cluster headache. Indomethacin, a specific NSAID, may be effective for headache that is similar to cluster like paroxysmal hemicrania and hemicrania continua.
- Opioids are a last resort option due to their potential for addiction and rebound headache. They should only be prescribed under the supervision of an expert center.
What are the treatments to manage cluster headache episodes?
Patients should be aware that research on cluster headache is difficult as it is uncommon, unpredictable, and so severe that patients may be reluctant to engage in placebo studies.
Here are commonly used options to alleviate bouts:
- Verapamil (a calcium channel blocker)
- Occipital nerve blocks with steroids
- Oral prednisone
Other treatment options, although supported by limited scientific evidence, include topiramate, lithium, valproate, intravenous DHE (which cannot be used at the same time as triptans), and gabapentin. Numerous other treatments have been attempted on only a small number of patients.
What about CGRP antibodies for cluster headache?
Galcanezumab (Emgality) has been studied for cluster and has shown effectiveness in decreasing the number of attacks in episodic cluster headache. It is the first drug approved for cluster headache prevention in Canada and the USA. Galcanezumab is well tolerated and administered via an auto-injector with one dose per month until the bout concludes. Patients who respond well to galcanezumab may find it beneficial for managing their bouts, especially considering the side effects associated with verapamil and the challenges of accessing nerve blocks.
I heard that psilocybin (magic mushrooms) can be used for cluster headache?
Psilocybin acts on the serotonin system and, from a scientific perspective, may be effective for cluster headache as it is similar to methysergide, a previously used drug that is no longer available due to risks of organ fibrosis.
Due to its status as an illicit substance, psilocybin cannot be legally studied. However, patient registries suggest that small doses of psilocybin may effectively alleviate cluster headache bouts.
For more information on cluster headache, consider visiting resources such as Clusterbusters and OUCHUK.
References
- Hoffmann J, May A. Diagnosis, pathophysiology, and management of cluster headache. Lancet Neurol. 2018;17(1):75-83.
- Tepper SJ, Stillman MJ. Cluster headache: Potential options for medically refractory patients (when all else fails). Headache. 2013;53(7):1183-90.
- Becker WJ. Cluster headache: Conventional pharmacological management. Headache. 2013;53(7):1191-6.
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