2. β Cluster headaches are excruciating attacks of neurovascular
pain in one side of the head, often felt behind the eye.
β Cluster headaches occur in cyclical patterns or clusters, which
gives the condition its name.
Whatareclusterheadaches(CH)?
3. β CH are much more painful than migraines or any other type of
headache. Sufferers often call them 'suicidal headaches'
because they're so severe.
β Cluster headaches may be the most painful
condition known to medical science.
β The pain is described as stabbing, drilling,
burning or squeezing.
CharacteristicsofPain
4. β The first complete description of
cluster headache was given by the
London neurologist Wilfred Harris in
1926, who named the disease
migrainous neuralgia.
β Descriptions of CH date to 1745 and
probably earlier.
ALittleBitofHistory
5. β The condition was originally named Horton's cephalalgia after
B.T. Horton, a US neurologist who postulated the first theory
as to their pathogenesis.
β His original paper describes the severity of the headaches as
being able to take normal men and force them to attempt or
complete suicide.
ALittleBitofHistory
Our patients were disabled by the disorder and suffered from bouts
of pain from two to twenty times a week. They had found no relief
from the usual methods of treatment. Their pain was so severe that
several of them had to be constantly watched for fear of suicide.
Most of them were willing to submit to any operation which might
bring relief. [B.T. Horton, 1939 ]
6. β Bouts of frequent attacks (cluster periods), may last from
weeks to months, usually followed by remission periods when
the headache attacks stop completely.
β The starting date and the duration of each cluster period may
be consistent from period to period. For example, cluster
periods may occur seasonally, such as every spring or every
fall.
β Chronic cluster periods may continue for more than a year,
or pain-free periods may last less than one month.
CharacteristicsoftheBouts: chronicCH
8. β A cluster headache strikes quickly, usually without warning.
β Most people (~90%) have only episodic cluster headaches.
β In episodic cluster headaches, the cluster headaches occur for
one week to a year, followed by a pain-free remission period,
that may last as long as 12 months before another cluster
headache develops.
β Some people have a single cluster headache cycle and never
have another one.
CharacteristicsoftheBouts: episodicCH
9. β Headaches usually occur every day during a cluster periods,
sometimes up to 8 times a day.
β A single attack may last from 15 minutes to 3 hours.
β The attacks often happen at the same time within each 24-
hour day.
β The majority of attacks occur
at night, usually one to two
hours after you go to bed.
β The pain usually ends as
suddenly as it begins, with
rapidly decreasing intensity.
PeriodicityandDurationoftheAttacks
10. β Cluster attacks usually occur with clocklike regularity during a
24-hour day, and the cycle of cluster periods often follows the
seasons of the year.
β These patterns suggest that the body's biological clock is
involved. In humans, the biological clock is located in the
hypothalamus.
β Hypothalamic dysfunction may
explain the timing and cyclical
nature of cluster headache.
Cause:Hypothalamicdysfunction?
11. β Positron emission tomography (PET) and voxel-based
morphometry have identified the posterior hypothalamic
gray matter as the key area for the basic defect in Cluster
attacks.
β Research suggests that the hypothalamus
becomes overactive during each attack.
β However, it is not known what causes
this overactivity.
Cause:Hypothalamicdysfunction?
12. β Average activation across nine cluster headache patients
during an acute right-sided attack compared to the
headache-free resting state. PET demonstration of
hypothalamic activation in cluster headache:
Cause:PETandMRAfindings
13. β During an attack, the hypothalamus is thought to release
neurotransmitters (such as histamin).
β These activate a nerve pathway in the base of the brain (the
trigeminal-autonomic reflex pathway) causing the pain and
other symptoms.
β The trigeminal nerve is the main
nerve of the face responsible for
sensations (such as heat or pain).
Cause:Hypothalamicoveractivity
14. β When activated, the trigeminal nerve causes the eye pain
associated with cluster headaches.
β The trigeminal nerve also stimulates another group of
nerves that causes the eye tearing and redness, nasal
congestion, and discharge associated with cluster attacks.
Cause:activationoftrigeminalnerve
15. β The nerve overactivity may also cause vasolidation of the
arteries (such as internal carotid and superior cerebellar
arterys) in the affected side of the brain.
β These blood vessels then press on nearby brain tissues and
nerves, which can cause pain.
Cause:vasodilationofthearteries
16. β Cluster headaches affect around 60 up to 280 per 100,000.
β E.g.: up to ~170'000 people in Italy or up to ~880'000 in USA
β Males are two to four times more likely to develop cluster
headache than females
β The first cluster typically develops between the ages of 20 to
40 years, but it can start at any age!
Epidemiology:whogetsclusterheadaches?
17. β Smoking. Many people (~80%) who get cluster headache
attacks are smokers.
β Alcohol use. Alcohol can trigger an attack if you're at risk of
cluster headache.
β A family history. If a parent or sibling has ever had a cluster
headache, you may have an increased risk of cluster
headaches.
β Anyone can be affected!
β They were diagnosed with CH: Franz Kafka, Frank Carpa,
Thomas Jefferson, Harry Potter (Daniel Radcliffe :)
Riskfactors
18. β There's no cure for cluster headaches, ordinary painkillers do
not work.
β The goal of treatment is to decrease the severity of pain,
shorten the headache period and prevent the attacks.
Management&Prevention
19. Preventive therapy starts at the onset of the cluster episode with
the goal of suppressing attacks.
β Calcium channel blockers,
β Corticosteroids,
β Lithium carbonate,
β Nerve block,
β Ergots (vasoconstricting agent),
β Melatonin,
β others.
Attackprevention
20. β Oxygen. Briefly inhaling 100 percent oxygen through a mask at
a minimum rate of at least 12 liters a minute provides dramatic
relief for most who use it.
β Triptans, it causes blood vessels to narrow, reducing
bloodflow to the brain.
β Octreotide, an injectable synthetic version of the brain
hormone somatostatin.
β Local anesthetics. The numbing effect of local anesthetics,
such as lidocaine, may be effective against cluster headache
pain in some people when given intranasal.
β Dihydroergotamine.
Acuteattacktreatment
21. οΏ€ Γ€
β Rarely doctors recommend surgery for peoplewho don't find relief
with aggressive treatment or who can't tolerate the medications.
β Surgical procedures (such as radiofrequency thermocoagulation or
gamma knife radiosurgery) for CH attempt to damage the nerve
pathways thought to be responsible for pain.
β The long-term benefits of surgery are disputed.
Also, because of the possible complications,
including muscle weakness in the jaw or
sensory loss in certain areas of the face
and head
SurgeryTreatment
22. As scientists learn more about the causes of cluster headache, they're
able to develop more-selective treatments for the condition.
β Neurostimulation: a procedure in which a wire electrode is burrowed
under the skin in the back of the neck region near the occipital nerve,
and when electrical stimulation is provided, the cluster headaches
can be turned off.
Newmethods:neurostimulation
23. β In this procedure, stimulator is placed into the hypothalamus and
connected to a generator that changes brain's electrical
impulses.
β DBS of the hypothalamus may provide relief for people with
severe, chronic CH that haven't been successfully treated with
other medications.
Newmethods:deepbrainstimulation
26. β Hypothalamus controls the autonomic nervous system, that is responsible for
maintaining homeostasis
β heart rate, blood pressure, body temperature, fluid and electrolyte balance, including thirst,
appetite and body weight, glandular secretions of the stomach and intestines, sleep cycles,
circadian rhythm.
β Hypothalamus controls the hypophysis (pituitary)
β Pituitary is the most important endocrine gland and is often referred to as the "master
gland", it controls most of the other endocrine glands in the body such as the thyroid,
adrenal gland, testis and ovaries. By controlling the hypophysis the hypothalamus exerts
control over most endocrine system. It is considered to be the link between the nervous
system and the endocrine system.
β Emotion and behavior are a function of the hypothalamus, the limbic system, and
the prefrontal cortex
β Hypothalamus may be the integrator of afferent information received from other areas of the
nervous system and brings about the physical expression of emotion; it can produce an
increase in the heart rate, elevate the blood pressure, cause dryness of the mouth, flushing
or pallor of the skin, sweatingand massive peristaltic activity of the GIT.
Appendix:Hypothalamusfunctions
28. References
1. Diseases and Conditions: Cluster headache, http://www.mayoclinic.org
2. Cluster headaches, http://www.nhs.uk
3. Cluster Headache, http://emedicine.medscape.com
4. Migraines & Headaches Health Center, http://www.webmd.com
5. Cluster Headaches, http://www.patient.co.uk
6. Surgical options for cluster headache, http://www.mhni.com
7. Cluster headaches, http://wikipedia.org
8. Matharu M, Goadsby P (2001). "Cluster Headache". Practical Neurology 1: 42.
9. Noshir Mehta, etl. Head, Face, and Neck Pain Science, Evaluation, and Management. John Wiley & Sons. pp. 199
10. PET and MRA findings in cluster headache and MRA in experimental pain A. May, MD etl.
11. PET demonstration of hypothalamic activation in cluster headache, Peter J. Goadsby, MD, PhD, DSc, and Arne May, MD
12. Symptomatic cluster headache: a review of 63 cases, Bengt Edvardssoncorresponding author, Springerplus. 2014; 3: 64.
13. Hypothalamic Involvement and Activation in CH, Arne May, MD etl., Current Pain and Headache Reports 2001, 5:60β66
14. Cluster headache: what has changed since 1999? Massimo Leone etl. Springer-Verlag Italia 2013
15. An Overview of the Hypothalamus, http://www.endocrineweb.com
16. Functions of the Hypothalamus, http://courses.cvcc.vccs.edu
