Cluster Headaches
meduploader - 05-14-09 13:42

Excruciating headache pain
Duration of typical attack - 15 to 180 minutes
Symptom-free intervals vary from 1 to 48 hours
Frequency : up to 8 attacks/day
Headache attacks come in clusters daily or at variable periods.
Nausea, photophobia and phonophobia
Tends to occur more in nights- The headaches have a predilection for the first rapid eye movement (REM) sleep phase so the cluster patient will awaken with a severe headache 60 to 90 minutes after falling asleep
Look for presence of autonomic symptoms : Tearing, Conjunctival injection, Ptosis , Rhinorrhea , Nasal congestion , Forehead and facial sweating and Miosis
Note the behavior during attacks (usually agitated, unlike in migraine where the patient is quiet and withdrawn!)
Rx:
Identify and recommend that patients avoid trigger factors of cluster headache such as: Alcohol , Smoking , Solvents , Altitudes above 5000 feet , High temperatures , Altered sleep schedules, e.g., afternoon naps, work shift changes, traveling across time zones, delay or advanced sleep phase
Acute Rx : Give 100% oxygen administered by nonrebreather face mask at 7 to 15 L/min for 15 to 30 minutes and repeat as needed.
To treat acute attacks, consider using separately and then combine as necessary:
Subcutaneous or intranasal sumatriptan, or nasal zolmitriptan
Intramuscular, subcutaneous, or intravenous DHE
Oral or rectal ergotamine
Other options : oral corticosteroids, Ipsilateral occipital nerve block
Prophylactic medications are started once cluster headaches begin but are not used during remissions
given that months to years may elapse between clusters. Such medications include verapamil (first-line
prophylactic treatment for cluster headache), lithium (direct comparison to CCBs showed that both are
equaly effective , but verapamil has better side effecs profile), prednisone (a taper of oral steroids is often
used at the beginning of a cluster, long term use is not recommended due to side effects), valproate, and
methysergide.