We are again in a cluster season. We do not see any cluster headache patients for months and then dozens come in within weeks. It is not allergies, barometric pressure or any other earth phenomena that trigger cluster headaches in so many people at once. It has been speculated that solar activity may be the trigger and I just checked the NASAs Solar Dynamics Observatory website and found that the sun has “active regions galore”. I wrote about solar activity as a possible culprit last October when we had another wave of cluster patients. Unfortunately, there is not much we can do about the sun, but we do have many effective treatments for cluster headaches, including intravenous magnesium, occipital nerve blocks, oxygen, injectable sumatriptan, verapamil, and for chronic cluster headaches, Botox injection.

A recent study by British neurologists in the journal Headache described the severe impact of cluster headaches on quality of life and neuro-psychological symptoms. The researchers found that cluster headache patients had normal intelligence and executive functions, but had worse working memory, disturbance of mood, and poorer quality of life compared with healthy controls. Similar findings have been found in patients with other chronic pain conditions as well. It is most likely that cognitive impairment and mood changes can be reversed with effective treatment of pain.

Cluster headaches cause more severe pain than any other type of headaches. Some patients even call them suicide headaches because they provoke thoughts of suicide. The name comes from the fact that they occur in clusters – every day for a couple of months and then they go away for a year or longer. In those with chronic cluster headaches they never go away. The headaches are brief – anywhere from 30 minutes to 3 hours. They are always one-sided, with pain usually around the eye, and are accompanied by tearing, nasal congestion, and sometimes restlessness. More men than women suffer from them.

Treatment of cluster headaches can be very effective. A 10-day course of prednisone or an occipital nerve block can abort the entire cluster. We also have preventive drugs, such as a blood pressure medicine, verapamil (used in high doses), epilepsy drugs, and lithium. These are taken daily to prevent headaches. To treat individual attacks, inhalation of 100% oxygen under high flow, zolmitriptan nasal spray (Zomig NS), and sumatriptan (Imitrex) injections can be true life savers.

Some of the alternative therapies that have been reported to help include melatonin, intranasal capsaicin (hot pepper extract), and an herbal product, Boswellia (Nature’s Way is a good brand for herbals).

Unfortunately, there are some cluster headache sufferers who do not respond to any of these treatments. We even treated some patients with intravenous histamine, which requires hospital admission and two of my patients were implanted with a vagus nerve stimulator (with good relief).

Some cluster patients have been found to have low testosterone levels and treating them with testosterone seems to help.

This testosterone connection led to trials of a fertility drug, clomiphene citrate (Clomid). Clomiphene enhances testosterone production and binds to hypothalamic estrogen receptors, which is why it was considered as a treatment for cluster headaches. A second case of successful treatment of cluster headaches with Clomid has just appeared in the journal Headache. This was a case of a 65-year-old man with a 17-year history of chronic cluster headaches who did not respond or had significant side effects to many cluster headache preventive medications including verapamil, lithium, valproic acid, topiramate, baclofen as well as greater occipital nerve blocks and inpatient hospitalization.

The patient experienced 3-5 headaches per day. On Clomid (100 mg/day) he became 100% pain-free and remained so for three and half years with only mild fatigue as a side effect. He then had cluster headache recurrence and did well on gabapentin for another 3 years, but then his headaches returned. Clomiphene was restarted, and he became pain-free once again.

Clomid should be considered when the usual preventive drugs for cluster headaches are ineffective.

Cluster headaches usually occur once or twice a year for a period lasting from a few weeks to a few months. During those periods, they occur daily or more than once a day. Interestingly, these episodes of cluster headaches tend to occur at the same time of year in many patients, but not always at the same time of year. Looking at our data, we have found that in some years many cluster patients developed their attacks in August, another year, in November, and this year, it has been September – October. This year, we are also seeing many patients whose cluster headaches are not responding to usual treatments.

It does not appear that barometric pressure or allergies are responsible for triggering cluster headaches. One unsubstantiated theory is that the solar activity is responsible for bringing on cluster headaches. This report in the Wall Street Journal indicates that we are currently going through a period of an unusually intense solar activity. Perhaps this is why some of our cluster patients are having unusually severe headaches.

Oxygen inhalation is a proven method of treating cluster headaches. The patient usually rents a large oxygen tank and breathes in pure oxygen through a mask whenever he gets an attack (it is usually a he since 5 times as many men suffer from cluster headaches as women). Demand valve oxygen (DVO) is a promising new oxygen delivery system for the acute treatment of cluster headaches, according to a recent report by Dr. Todd Rozen.

DVO delivers oxygen to the user as soon as they inhale from an attached mask and the amount of oxygen is controlled by how fast they are breathing. DVO is capable of delivering much more oxygen than by just breathing it through a regular mask. In the study 3 patients tried both DVO and a regular mask. All patients had chronic cluster headaches. On DVO all 3 subjects became pain free; 2 of 3 became pain free on a regular mask, while the third subject needed 30 minutes to get to mild pain. Patients using DVO became pain free faster than when a regular mask was used. This was a very small sample and bigger studies are needed, but DVO appears to be at least as effective for acute treatment for cluster headaches as inhalation of oxygen through a regular mask.

A new treatment developed by Belgian neurologists was reported to help patients with chronic refractory cluster headaches. The name cluster headaches originates from the fact that headaches occur in clusters, typically once a year for a period of a month or two, during which headaches occur daily. Unfortunately, in some patients cluster headaches are chronic and occur continuously. Some of these chronic cluster patients respond to medications, such as verapamil, topiramate, lithium or Botox injections. A small number of patients fails to respond to any of the usual therapies and are considered refractory to treatment. Because the pain of cluster headaches is extremely severe and because headaches occur daily and often more than once a day these patients often become despondent. Out of desperation, doctors have tried different unproven and at times risky treatments, such as deep brain stimulators with electric probes implanted deep into the brain. This is obviously a very invasive procedure that has resulted in strokes and deaths. I have treated two patients with a much less invasive Vagus Nerve Stimulator and these two responded well.
Dr. Jean Schoenen and his colleagues implanted 28 patients with chronic refractory cluster headaches with a miniature neurostimulator implanted in the back of the nasal cavity, near the sphenopalatine ganglion. This ganglion has been injected and anesthetized (with lidocaine and cocaine) in an attempt to relieve various pains for many years. The stimulator was implanted by a neurosurgeon in an out-patient visit and the procedure leaves no visible scar. Once implanted, the device can be activated by a remote controller which the patient holds near the face. The study was blinded in that some patient were given either very mild or no stimulation at all. The researchers hoped that by stimulating sphenopalatine ganglion for 90 seconds patients would be able to stop a cluster attack. The results showed that only 7 (25%) of patients were able to abort an attack, but surprisingly another 10 (36%) reported that after trying to treat 30 attacks (over 3 – 8 week period) the frequency of their attacks dropped by more than 50%. Headache-related disability improved in 64% of patients. Patients were allowed to use acute medications to stop individual attacks and only 31% of those who received real stimulation used them, while these drugs were used by 78% of those given mild or no stimulation. The most common side effect was an unpleasant sensation in the face, experienced by 81% of patients but these symptoms resolved within 3 months. Two patients had infections and another two had their stimulator drift out of place and had to have it removed. The stimulator is known as ATI Neurostimulator System and it does not preclude having MRI scans done in these patients. The manufacturer of this device launched a large multi-center trial of this device in Europe, both for chronic cluster and disabling migraine headaches.