The
cluster headache (cluster headache CH), called by French authors headache suicide, has been described with a variety of terms, including paroxysmal nocturnal headache, migraine neuralgia, headache histamine (Horton) , red migraine, erythromelalgia cephalic . The definition of cluster headache, coined by Kunkle in '52, is one that has prevailed.
Kunkle intended to describe the characteristic tendency to cluster attacks in a limited period of time (about 6 / 12 weeks) he called "cluster period" that is "cluster . "Attacks are grouped with seasonal pattern for the active phases of the disease (" cluster periods ") with frequency and circadian / ultradian that more attacks during the day.
They typically occur in early spring and autumn but also at changes in lifestyles. The attacks also alternate in briefcase: usually lasts about three hours and may recur several times during the same day, especially early in the afternoon and night. About half of patients with CH is awakened suddenly in the night by the onset of a painful attack.
The International Headache Society (IHS) has established certain criteria: frequency of occurrence is from an attack every 2 days to 8 attacks per day. They last from a minimum of 15 to a maximum of 180 minutes. The periods t greater risk are those between one and three in the morning, around nine in the evening and between one and two in the morning. The
cluster headache is characterized by a constant unilateral orbital location, tends to recur nightly or several times during the night and day, for a period of 2-8 weeks, sometimes much longer, followed by a complete no attacks for several months or even several years (hence the term "cluster").
The pain is perceived in depth and around the eye, it is intense and usually non-pulsating and often radiates to the forehead, temple and cheek. I understand the phenomena associated with the obstruction of one nostril followed by rhinorrhea, conjunctival congestion and more rarely by nausea, vomiting, miosis, ptosis, reddening and swelling of the cheek with a duration of 10-15 minutes at about 3 hours. The homolateral temporal artery may become apparent and painful during the attack and the scalp and face may show hyperalgesia. The pain can disappear in an attack as quickly as it appeared or regress gradually. During a mass attack is almost always concerned la stessa orbita e così pure negli attacchi ricorrenti. Nel periodo libero da attacchi, l'alcool, che abitualmente nel corso di una salva di attacchi scatena la cefalea a grappolo, non ha questo affetto.
L'intensità del dolore può essere così insopportabile che sono stati riportati persino casi di tentato suicidio. L'immagine che meglio caratterizza questo tipo di cefalea è quella del soggetto che si contorce o che continua a camminare nervosamente al buio, lacrimando abbondantemente da un occhio e col viso contratto dal dolore. La distribuzione del dolore è sempre unilaterale: il lato più spesso interessato è quello destro (49,1%), seguito da quello sinistro (35,4%) e dai casi di alternanza di lato (15.5%).
EPIDEMIOLOGY AND CHARACTERISTICS The International Headache Society (IHS) has established certain criteria: frequency of occurrence is from an attack every 2 days to 8 attacks per day. They last from a minimum of 15 to a maximum of 180 minutes. The periods t greater risk are those between one and three in the morning, around nine in the evening and between one and two in the morning. The
cluster headache is characterized by a constant unilateral orbital location, tends to recur nightly or several times during the night and day, for a period of 2-8 weeks, sometimes much longer, followed by a complete no attacks for several months or even several years (hence the term "cluster").
The pain is perceived in depth and around the eye, it is intense and usually non-pulsating and often radiates to the forehead, temple and cheek. I understand the phenomena associated with the obstruction of one nostril followed by rhinorrhea, conjunctival congestion and more rarely by nausea, vomiting, miosis, ptosis, reddening and swelling of the cheek with a duration of 10-15 minutes at about 3 hours. The homolateral temporal artery may become apparent and painful during the attack and the scalp and face may show hyperalgesia. The pain can disappear in an attack as quickly as it appeared or regress gradually. During a mass attack is almost always concerned la stessa orbita e così pure negli attacchi ricorrenti. Nel periodo libero da attacchi, l'alcool, che abitualmente nel corso di una salva di attacchi scatena la cefalea a grappolo, non ha questo affetto.
L'intensità del dolore può essere così insopportabile che sono stati riportati persino casi di tentato suicidio. L'immagine che meglio caratterizza questo tipo di cefalea è quella del soggetto che si contorce o che continua a camminare nervosamente al buio, lacrimando abbondantemente da un occhio e col viso contratto dal dolore. La distribuzione del dolore è sempre unilaterale: il lato più spesso interessato è quello destro (49,1%), seguito da quello sinistro (35,4%) e dai casi di alternanza di lato (15.5%).
The clinical picture of cluster headache is usually so characteristic that it can not be confused with any other disease. However, in doubtful cases may be helpful to the differential diagnosis with migraine, trigeminal neuralgia, carotid aneurysm, a brain tumor or a sinusitis. Appropriate investigations (CT scan with contrast, brain MRI with contrast angiographic sequences + possible) will always be able to exclude these conditions.
The CH has a prevalence of 0.7%. It clearly dominates in the male and the average age of onset is around 20-30 years, but it is possible onset after 50 years as well, although very unlikely, an onset in childhood.
are a distinct form episodic and a chronic form . The episodic form is characterized by active periods with high frequency in the attacks, separated by months or years of remission, while chronic is characterized by attacks that do not have episodes of remission. 80% of patients maintain the episodic form throughout the course of the disease, about 13% changes in the chronic form and in the remaining 7% of cases there has been a trend characterized by combining forms.
were identified in these particular physical traits patients as a ruddy color, deep wrinkles, skin to "orange peel", telangiectasia, narrow palpebral fissures, broad skull and chin height and significantly higher than the healthy population.
E 'was also outlined a profile for this type of patient: a very busy professional male, belonging to medium-high socio-economic status who leads a stressful life, often heavy drinker and smoker.
several years are also increasing cases of female cluster headache. This seems related to the fact that women are taking positions and professional lifestyles increasingly challenging and ever greater responsibilities.
THERAPY
The treatment can be distinguished: symptomatic therapy, prophylactic therapy and non-pharmacological therapy .
Symptomatic treatment Symptomatic therapy aims to treat the attack as soon as it occurs in the patient by determining the resolution or mitigation of significant pain.
Sumatriptan subcutaneously : It 's the most effective drug. The most common side effects are transient pain at the injection site. Other side effects are tingling, heat, heaviness, pressure or tightness. These symptoms are temporary and can affect any part of the body, including chest and throat. The Sumatriptan can be considered the drug of first choice.
Oxygen inhalation : The 100% oxygen is administered at a dose of 6-7 l / min for 15 min. It can be considered a viable second choice if there are any contraindications to the use of sumatriptan, or if the seizures are numerous daily.
Indomethacin : intramuscularly or 50 or 100 mg suppositories
Indomethacin : intramuscularly or 50 or 100 mg suppositories
Other drugs (sumatriptan nasal spray, zolmitriptan, oxygen iperbarica, ergotamina in associazione a caffeina, diidroergotamina, lidocaina) non sono ritenuti efficaci dai membri dell'Ad Hoc Committee.
Terapia di profilassi
Gli obiettivi principali della terapia di profilassi sono di ottenere una rapida scomparsa degli attacchi e di conseguenza una conclusione della fase di grappolo. Obiettivi secondari sono la riduzione della frequenza, intensità e durata degli attacchi.
Verapamile : Il verapamile è oggi considerato il farmaco di prima scelta nel trattamento di profilassi della CH sia episodica che cronica. L'efficacia è stata confermata nella maggioranza dei pazienti and the drug has proved with few side effects, even at higher doses.
Prednisone: Prednisone is effective and rapid preventive action in the treatment of episodic CH, as a second choice. In the chronic form the drug is able to induce a rapid reduction in crisis and be beneficial in the early stages of treatment, even when the preventive drugs have not begun to be effective. As long as there are not any side effects, this drug is used only to induce remission in severe cases with high attack frequency and intensity, particularly in the middle phase of the bunch. The treatment period should not exceed 3 weeks.
Lithium: Lithium has been used in various medical and psychiatric conditions and has proven to be efficacious in the prophylaxis of chronic CH in that episode, is now widely used in clinical practice.
must make periodic checks of litiemia and before and during the treatment, renal function and thyroid. The most common side effects with lithium include tremor, diarrhea, mental confusion, should be used with caution in combination with calcium channel blockers, some selective serotonin reuptake inhibitors, diuretics, indomethacin and diclofenac.
Melatonin: Serum and urinary of melatonin are reduced in patients with CH, especially during the phase of the bunch. And 'demonstrated efficacy of oral administration of 10 mg of melatonin.
valproic acid: In a study of valproic acid has been used to treat 13 patients with episodic CH. In 9 of these have seen the disappearance of the crisis after 1-4 days of treatment. The members of the Ad Hoc Committee, however, have not expressed an opinion of efficacy.
Topiramate: A study has shown improvement in 10 patients with CH after administration of topiramate. There was an opinion expressed by members of the Ad Hoc Committee's effectiveness.
In a recent study (Neurol India, 2010 Mar-Apr) topiramate was administered to 13 patients with episodic CH. Nine patients had remission of the headache with a daily dose of 273 mg and patients with chronic CH showed remission of symptoms with a dose of 400 mg. The authors concluded that this study suggests efficacy of topiramate in the treatment of CH.
The drug of choice in the treatment of crisis, since the early 90s, the that sumatriptan, administered subcutaneously, is effective in a few minutes in 95% of cases. The attacks of mild to moderate intensity is also effective ' oxygen, inhaled at a rate of 7-10 l / min for about 15 minutes. An alternative is the ' indomethacin, and intramuscularly in 50 or 100 mg suppositories. It 'also possible the application of nasal lidocaine (4-6%), although this technique is less common and more difficult to enforce.
For both the episodic form than for the chronic prophylactic drug of first choice instead verapamil. Before starting treatment you should run an ECG: This medicine is in fact contraindicated in the presence of a significant bradycardia or atrioventricular block.
many users and also the lithium carbonate that contraindicated in patients with hypertension, neuropathy and thyroid disease or kidney disease, is more effective in chronic forms, rather than in episodic. In the episodic form
corticosteroids prednisone and dexamethasone are effective and rapid preventive action. In the chronic form these drugs induce a rapid reduction of the crisis especially in the early stages of treatment when the preventive drugs have not yet begun to exert their action.
In non-responders to monotherapy, may be indicated groups: verapamil + lithium, steroids and verapamil + lithium + steroids in chronic forms.
When they are identifiable, are also deleted any precipitating factors such as alcohol and smoking, which would still be able to help during the crisis only in clusters, that is when the disease is already active. Prophylaxis should be instituted early, especially in episodic form, and then continued for at least two weeks after the disappearance of the crisis. The withdrawal should be gradual, and reappear when the crisis actually goes back more gradually at the therapeutic dose. When you see the next phase of the cluster, the treatment should always be taken with similar arrangements.
non-drug therapy in patients with chronic CH in which medical therapy is ineffective surgical treatment may be the only alternative.
Patients should be treated surgically essere attentamente selezionati:
1) Totale formacoresistenza
2) Cefalea strettamente localizzata allo stesso lato
3) Dolore prevalentemente nella regione della branca oftalmica del nervo trigemino
4) Pazienti con personalità stabile e con bassa tendenza a somatizzare.
Le procedure chirurgiche che ottengono i migliori risultati sono quelle dirette verso il nervo trigemino nella sua componente sensitiva, in particolare la rizotomia retrogasseriana percutanea con radiofrequenze (PRFR) e la rizolisi retrogasseriana percutanea con glicerolo (PRGR). Tali metodiche sono particolarmente efficaci nella nevralgia trigeminale.
E' stata anche utilizzata la Gamma-Knife nel trattamento dei pazienti con CH. Il sollievo è was immediate, and patients were pain free at follow-up carried out after more than eight months.
about this technique is not known at the time of its maximum effectiveness, tolerability and duration of the procedure. Being a non-invasive procedure may represent a good alternative. It is not without risk because it can produce, if not well done, even radionecrotiche injury.
DEEP BRAIN STIMULATION (deep brain stimulation). The precision with which
seasonal periods of cluster recur and, especially, the rhythm of painful crises that occur at specific times of day and night sent to the hypothesis of an involvement of the hypothalamus.
Nel 1998 il neurologo tedesco Arne May ha evidenziato tramite PET che, durante l'attacco doloroso, si verifica un'attivazione della regione ipotalamica omolaterale al dolore e l'anno dopo, utilizzando la risonanza magnetica funzionale, ha dimostrato che in quella stessa area si verifica anche un'alterazione della densità neuronale.
Questa linea di ricerca ha così portato ad identificare un possibile target cerebrale per il trattamento della cefalea a grappolo.
La procedura consiste nella stimolazione inibitoria del nucleo ipotalamico posteriore durante la fase attiva di malattia mediante l'introduzione di un microelettrodo in questo nucleo.
Il Prof. Gennaro Bussone dell'Istituto Neurologico "Carlo Besta" di Milano published a recent paper in which he outlined the results of this technique. Over the past ten years it has proved safe, with side effects are extremely rare and negligible mortality, with the added benefit of a possible complete reversibility. Professor Bussone reports that, in cases treated at his center, after more than two years there has been a persistent efficacy without side effects and others were also treated 6 patients who experienced a progressive reduction in crisis until their complete disappearance, without side effects and buy a quality of life that previously was very bad.
Lithium: Lithium has been used in various medical and psychiatric conditions and has proven to be efficacious in the prophylaxis of chronic CH in that episode, is now widely used in clinical practice.
must make periodic checks of litiemia and before and during the treatment, renal function and thyroid. The most common side effects with lithium include tremor, diarrhea, mental confusion, should be used with caution in combination with calcium channel blockers, some selective serotonin reuptake inhibitors, diuretics, indomethacin and diclofenac.
Melatonin: Serum and urinary of melatonin are reduced in patients with CH, especially during the phase of the bunch. And 'demonstrated efficacy of oral administration of 10 mg of melatonin.
valproic acid: In a study of valproic acid has been used to treat 13 patients with episodic CH. In 9 of these have seen the disappearance of the crisis after 1-4 days of treatment. The members of the Ad Hoc Committee, however, have not expressed an opinion of efficacy.
Topiramate: A study has shown improvement in 10 patients with CH after administration of topiramate. There was an opinion expressed by members of the Ad Hoc Committee's effectiveness.
In a recent study (Neurol India, 2010 Mar-Apr) topiramate was administered to 13 patients with episodic CH. Nine patients had remission of the headache with a daily dose of 273 mg and patients with chronic CH showed remission of symptoms with a dose of 400 mg. The authors concluded that this study suggests efficacy of topiramate in the treatment of CH.
The drug of choice in the treatment of crisis, since the early 90s, the that sumatriptan, administered subcutaneously, is effective in a few minutes in 95% of cases. The attacks of mild to moderate intensity is also effective ' oxygen, inhaled at a rate of 7-10 l / min for about 15 minutes. An alternative is the ' indomethacin, and intramuscularly in 50 or 100 mg suppositories. It 'also possible the application of nasal lidocaine (4-6%), although this technique is less common and more difficult to enforce.
For both the episodic form than for the chronic prophylactic drug of first choice instead verapamil. Before starting treatment you should run an ECG: This medicine is in fact contraindicated in the presence of a significant bradycardia or atrioventricular block.
many users and also the lithium carbonate that contraindicated in patients with hypertension, neuropathy and thyroid disease or kidney disease, is more effective in chronic forms, rather than in episodic. In the episodic form
corticosteroids prednisone and dexamethasone are effective and rapid preventive action. In the chronic form these drugs induce a rapid reduction of the crisis especially in the early stages of treatment when the preventive drugs have not yet begun to exert their action.
In non-responders to monotherapy, may be indicated groups: verapamil + lithium, steroids and verapamil + lithium + steroids in chronic forms.
When they are identifiable, are also deleted any precipitating factors such as alcohol and smoking, which would still be able to help during the crisis only in clusters, that is when the disease is already active. Prophylaxis should be instituted early, especially in episodic form, and then continued for at least two weeks after the disappearance of the crisis. The withdrawal should be gradual, and reappear when the crisis actually goes back more gradually at the therapeutic dose. When you see the next phase of the cluster, the treatment should always be taken with similar arrangements.
non-drug therapy in patients with chronic CH in which medical therapy is ineffective surgical treatment may be the only alternative.
Patients should be treated surgically essere attentamente selezionati:
1) Totale formacoresistenza
2) Cefalea strettamente localizzata allo stesso lato
3) Dolore prevalentemente nella regione della branca oftalmica del nervo trigemino
4) Pazienti con personalità stabile e con bassa tendenza a somatizzare.
Le procedure chirurgiche che ottengono i migliori risultati sono quelle dirette verso il nervo trigemino nella sua componente sensitiva, in particolare la rizotomia retrogasseriana percutanea con radiofrequenze (PRFR) e la rizolisi retrogasseriana percutanea con glicerolo (PRGR). Tali metodiche sono particolarmente efficaci nella nevralgia trigeminale.
E' stata anche utilizzata la Gamma-Knife nel trattamento dei pazienti con CH. Il sollievo è was immediate, and patients were pain free at follow-up carried out after more than eight months.
about this technique is not known at the time of its maximum effectiveness, tolerability and duration of the procedure. Being a non-invasive procedure may represent a good alternative. It is not without risk because it can produce, if not well done, even radionecrotiche injury.
DEEP BRAIN STIMULATION (deep brain stimulation). The precision with which
seasonal periods of cluster recur and, especially, the rhythm of painful crises that occur at specific times of day and night sent to the hypothesis of an involvement of the hypothalamus.
Nel 1998 il neurologo tedesco Arne May ha evidenziato tramite PET che, durante l'attacco doloroso, si verifica un'attivazione della regione ipotalamica omolaterale al dolore e l'anno dopo, utilizzando la risonanza magnetica funzionale, ha dimostrato che in quella stessa area si verifica anche un'alterazione della densità neuronale.
Questa linea di ricerca ha così portato ad identificare un possibile target cerebrale per il trattamento della cefalea a grappolo.
La procedura consiste nella stimolazione inibitoria del nucleo ipotalamico posteriore durante la fase attiva di malattia mediante l'introduzione di un microelettrodo in questo nucleo.
Il Prof. Gennaro Bussone dell'Istituto Neurologico "Carlo Besta" di Milano published a recent paper in which he outlined the results of this technique. Over the past ten years it has proved safe, with side effects are extremely rare and negligible mortality, with the added benefit of a possible complete reversibility. Professor Bussone reports that, in cases treated at his center, after more than two years there has been a persistent efficacy without side effects and others were also treated 6 patients who experienced a progressive reduction in crisis until their complete disappearance, without side effects and buy a quality of life that previously was very bad.
