Britt Talley Daniel M.D.
7777 Forest Lane Suite B-220
(972) 566-4556
Cluster Headache
The current international classification for headache (ICDH II 2004) lists Cluster Headache as an entity separate from migraine, although they have many similar features. Many persons with cluster headache have family members with migraine. Cluster headache predominates in men, four times as frequent as in women. The age range is usually mid- twenties to about sixty. These are very severe, quick onset, one sided headaches which consist of pain around the eye, temple, or cheek. There may be characteristic accompanying symptoms on side of the face, such as: drooping of the upper eyelid, smallness of one pupil, sweating above the eye, redness of the eye, tearing of one eye, nasal congestion, or drainage of clear fluid. The headaches come in time periods called clusters which usually last 6-8 weeks and consist of 1-8 headaches a day, lasting 20-40 minutes. The patient usually gets up and paces around the room. Nausea, vomiting, and sensitivity to light and sound may occur, but are not as prominent as that which occurs with migraine. The onset to peak of the headache is very quick—often in minutes. The headaches may track the clock, coming at the same time every day and they may characteristically occur one to two hours after going to sleep. During the cluster period drinking alcohol may aggravate the headache, but not at other times. The patients often have a driven, type A workaholic nature.
Acute Therapy
Hydrocortisone (prednisone, medrol dosepack) given orally for 7-10 days for cluster, will sometimes stop the attack.
Nasal Oxygen for cluster patients, and some migraine patients with clusters of short, quick headache. Oxygen is delivered from a canister through plastic tubing to a mask at a flow rate of 6-10 liters/min.
Triptans Imitrex (sumatriptan) given via the Stat Pen subcutaneously at 6 mg and Zomig nasal spray 5 mg.
Chronic Therapy
Depakote (Divalproex sodium) Comes as a delayed release oral capsule 125 mg, oral tablet 125, 250, 500 mg, and oral tablet extended release 250, 500 mg. The typical dose for migraine is 750-1500 mg given in divided doses. The initial dose for cluster headache is 250 mg bid and a typical dose of 600 to 2000 mg may be used for cluster headache. Common side effects—alopecia, weight gain, nausea, and tremor. Serious side effect—pancreatitis, liver failure, and thrombocytopenia. Blood levels can be monitored.
Lithobid (lithium carbonate) Comes as an oral capsule 150 mg, 300 mg, 600 mg, oral tablet 300 mg, and oral tablet extended release 300 mg, 450 mg. The typical dose for cluster headache is 600-900 mg/day in divided doses. Common side effects–drowsiness, tremor, urinary frequency, thirst. Serious side effect—nephrotoxicity and hypothyroidism. Monitor blood level periodically.
Verapamil, Calan Comes as an oral capsule extended release 100, 120, 180, 200, 240, 300, and 360, oral tablet 40, 80, and 120 mg, oral tablet extended release 120, 180, and 240 mg, and oral tablet extended release 24 hour 180 and 240 mg. The initial dose is 80-160 mg and the typical dose for migraine and cluster headache is 160-480 mg although occasional higher doses up to 960-1200 mg have been used for cluster headache. Common side effects–constipation, congestive heart failure, pedal edema, AV block, dyspnea, and inhibition of sperm motility (possibly resulting in infertility). Serious side effects—hypotension and dysrhythmias. It is advised to check EKG at baseline, at dose escalation, and every 6 months for long-term maintenance. The EKG abnormalities are not dose-dependent and can occur in patients on doses as low as 240 mg/day.[i] Some clinicians favor using the short rather than long acting preparation for ease with dose titration. “Neurological doses” (usually higher than 240 mg/d) have more potential serious heart block side effects than “cardiovascular doses” (80-240 mg/day).
BTD 100209
