Headache
4. HEADACHE TREATMENT
4.3. Cluster Headache
The intensity of each individual cluster headache attack is so severe that therapy must focus on prevention (see Box 6). In addition, most acute thera-pies will not become effective during the course of these brief attacks. Epi-sodic cluster headache is typically treated with preventive therapy for the ache Fig. 8. Therapeutic options for migraine, tension-type, and posttrauma headaches.
expected duration of the cluster cycle, usually approximately 6 weeks. Chronic cluster, which has no or only brief headache-free periods, is treated with daily, ongoing, preventive therapy. If patients are initially diagnosed when a cluster period has already reached peak severity, treatment with a short course of ste-roids is usually necessary. Plans should be made at that time, however, for initiation of preventive therapy at the start of the next cluster cycle.
Fig. 9. Choosing acute care medication.
Fig. 10. Choosing preventive therapy. Combining medication and alternative thera-pies maximizes treatment outcome.
Box 6
Treatment of Cluster Headache
• Episodic cluster (cluster duration ≥7 days, with pain-free period between clus-ters≥1 month)
Preventive therapy: onset of cluster
Discontinuation of nicotine and alcohol during cluster
240–480 mg/day verapamil for 6 weeks
2–8 mg/day methysergide for 6 weeks
Preventive therapy: cluster at maximum intensity at time of treatment initiation
Prednisone 10–60 mg/day for 1 week
Rescue therapy
6 mg subcutaneous sumatriptan
100% O2 7 L/minute for 10 minutes by face mask
Intranasal butorphanol
• Chronic cluster (cluster duration >1 year, with any pain-free periods during that year lasting <1 month)
Preventive therapy
Discontinuation of nicotine and alcohol
240–480 mg/day verapamil
250–1000mg/day valproic acid
900–1800 mg/day gabapentin
Rescue therapy
100% O2 7 L/minute for 10 minutes by face mask Box 5
Choosing a Triptan
• Weigh needs for immediate relief against convenience/desirability of oral therapy
Fastest relief from injectable or intranasal sumatriptan
Patients typically prefer oral formulations
Fast-acting oral triptans include rizatriptan, eletriptan, zolmitriptan, and sumatriptan
• Need for sustained relief
Add nonsteroidal anti-inflammatory drugs to fast-acting triptan (25)
Choose slower acting triptan
Naratriptan and frovatriptan
• Desire for convenient formulation
Orally disintegrating formulations (Maxalt MLT or Zomig ZMT)
• Sumatriptan nonresponders usually respond to alternative triptan.
Only 19% of sumatriptan nonresponders fail zolmitriptan and rizatriptan (24)
ductive cycle in women. Estradiol is an important pain modulator, directly influencing neural function through a variety of neurotransmitters important for transmitting pain signals, including endorphins, serotonin, γ-aminobutyric acid (GABA), and dopamine (27). Generally, estradiol protects against pain, reducing pain perception as estradiol levels rise. Therefore, the pain threshold increases and headache frequency decreases for the majority of women during pregnancy (28,29). Conversely, when estradiol levels fluctuate or drop from high to low levels—as occurs with ovulation, menses, the placebo week of oral contraceptives, and after delivery—headache frequency increases. Because estradiol levels fluctuate during the perimenopausal period, headaches tend to worsen while other somatic symptoms of menopause—e.g., hot flashes—occur during early menopause. Headaches may also be aggravated during meno-pause by estrogen supplementation (30).
Headache management in women should focus on either minimizing changes in estradiol levels with estrogen supplementation when a decline in estradiol levels is expected or by pharmaceutically manipulating other important neurochemicals, such as using antidepressants or triptans to modulate serotonin levels, valproate or gabapentin to modulate GABA, or antinausea medi-cations to modulate dopamine (see Boxes 7 and 8) (31). Consideration should also be given to the risk for adverse effects of medications on the developing fetus when treating headaches during pregnancy (see Box 9). Most medications that can be used safely during pregnancy can be continued when breastfeeding.
Injectable sumatriptan, which is restricted during pregnancy, may be used when by a nursing mother if she pumps her milk and discards it for 4 hours after an injection and supplements the baby’s feeding with stored milk.
5. SUMMARY
Managing chronic headache begins with a reliable headache history to aid the health care provider in identifying common headache patterns. Worrisome headaches are generally associated with new headache patterns, pain in the back of the head or neck, aging (>50 years old), or abnormal neurological ex-amination findings (21). A diary that is used to record both headache activity and medication use can be helpful to the clinician in correctly identifying
head-Box 7
Treating Menstrual Headache: Perimenstrual Prevention
• Hormone therapy
7-day 100-mg estrogen patch
Eliminate placebo week from oral contraceptives for 2 or 3 months
• Acute-care medications
Nonsteroidal anti-inflammatory drugs (excluding aspirin or ibuprofen)
2.5 mg naratriptan twice daily
2.5 mg frovatriptan once or twice daily
• Preventive medications
β-blocker
Antidepressant (excluding fluoxetine)
Calcium channel blocker
Antiepilepsy drug (valproic acid or gabapentin)
All medications should be used at usual dose for 3 days before the expected menstrual period and during first 2–4 days of menses. Do not use unless diary confirms headache occurrence exclusively in association with menses.
Box 8
Treating Headache During Menopause
• Determine if there has been a change in headache pattern notable enough to warrant additional evaluation
• Adjust estrogen replacement therapy if it aggravates headache
Use noncycling, transdermal route
Reduce estrogen dose
Change estrogen-replacement product
• Add standard headache-preventive therapy in conjunction with estrogen replacement
patterns, the contribution of medication overuse to headache, and the relation-ship of headache to menstruation. Identification and elimination of medication overuse is the first step in successful headache management. Choice of head-ache therapy depends on headhead-ache frequency and disability. Combining medi-cation and nonmedimedi-cation therapies maximizes treatment outcome.
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Bupropion
Gabapentin (in early pregnancy; stop in third trimester)
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Regular meals and sleep
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2. Features associated with potentially serious headache that requires additional evaluation include:
a. Posterior head or neck pain
b. Pain beginning after the age of 50 years c. Change in headache pattern
d. Abnormal neurological examination e. All of the above
3. The most common type of chronic headache seen in the primary care office is:
a. Migraine b. Tension-type c. Posttraumatic d. Cluster
4. Which of the following headaches is experienced as short pain episodes, typically lasting
<2 hours?
a. Migraine b. Tension-type c. Posttraumatic d. Cluster
e. Medication overuse
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From: Chronic Pain: A Primary Care Guide to Practical Management Edited by: D. A. Marcus © Humana Press, Totowa, NJ