Indescribable faceache
Drawing of I. Rubloff entitled "indescribeable faceache". (c) 2005, I. Rubloff, all rights reserved


Timothy C. Hain, MD • Page last modified: August 20, 2020

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Cluster headache is defined as excruciating unilateral head pain which occurs in brief episodes (15 minutes-2 hours). Clusters consist of headache that occur daily for 3 weeks to 3 months, then remit. Typically there are bouts in early July and early January. Thus cluster headaches are seasonal, and sometimes can be associated with other seasonal illnesses such as seasonal vertigo.

Cluster may awaken one from sleep (migraine and tension usually won't). Some experience flushing, droopy eye, nasal stuffiness, or eye tearing. Clusters are typically "side locked". They do not alternate sides. Men are affected 2 to 5 times more frequently than are women (reverse of migraine). Unlike the situation for migraine, menopause does not reduce the frequency and severity of headache in women. Perhaps related, attaining an advanced age does not reduce the frequency of cyclic vomiting either, which is treated somewhat similarly. There probably are several mechanisms for same symptom complex - migraine variant, sphenopalatine neuralgia, and perhaps a genetic syndrome involving circadian rhythms..

The reason for the peculiar periodicity of cluster headache has recently been discussed (Pringsheim T, 2002). There are two genes -- the PER or period gene located on the X chromosome and the timeless (TIM) gene. Both genes affect the suprachiasmatic (STC) nucleus of the hypothalmus. These genes generate products that control circadian rhythms. It seems reasonable to hypothesize that in cluster headache there is a disturbance of this clock.

Paroxysmal hemicrania

Paroxysmal hemicrania (PH) is ocasionally mistaken for cluster. Both disorders are short-lived, unilateral, and accompanied by ipsilateral autonomic features. The PH patients show a female predominance, a shorter attack duration (2-30 min), and often a greater attack frequency (5 or more/day). A prompt response to indomethacin confirms the diagnosis (Lipton et al, 2003)

Acute Treatment of Cluster:

Cluster headaches are extremely painful and the author's present practice is to use multiple medications simultaneously when it recurs. The author's usual protocol is to combine a triptan (injection or nasal spray) with steroids and verapamil for prevention.  The triptans are used for pain control, while waiting for the steroids and verapamil to take effect. McGeeney comments that injection, inhalation and nasal spray therapies are superior to oral treatment for acute treatment of cluster headache.

Below are acute treatments reported in the literature.

A new approach to acute cluster was reported by Khatami et al.  Xyrem (Sodium oxybate), which induces extremely deep sleep, was reported to be effective in cluster(2011).  It is our thought that as clusters normally occur in the middle of the night, someone on Xyrem might simply sleep through them.  This seems to us to be potentially a better way of managing them than many of the medications above. Xyrem, however, has major barriers to obtaining a rapid prescription.

Butorphanol nasal spray is best avoided due to alarming rates of abuse, addiction and even death McGeeney (2019).

Prevention of cluster headache

There are a number of peculiar treatments such as Civamide (related to hot peppers), Warfarin (a blood thinner) that we advise against. The protocol here aims for an INR between 1.5-1.9. There have also been some limited reports of utility for antiepileptic migraine medications such as topiramate, gabapentin and sodium valproate. We do not think that invasive treatment such as use of simulators are reasonable in any but the persons who have failed all else.