Various case reports on CH - interesting read

Annette · Various case reports on CH - interesting read

cluster headache and the sympathetic nerve.

OBJECTIVE: To determine the effect of a sympathetic block at C7 on cluster headache. BACKGROUND: Eleven patients presenting to a pain control unit with cluster headache were included in the study after giving informed consent. methods: In all patients, a mixture of 5 mL of 0.5% bupivacaine hydrochloride and 1 cc of methylprednisolone acetate was injected onto the base of the C7 transverse process. RESULTS: The injection was applied during the acute phase of headache in 6 patients and all experienced immediate and complete relief. The other 5 patients received the injection between attacks. Of the 11 patients treated, 8 went into remission by aborting the cluster. In some patients, repeated injections were given before the cluster was aborted. Three patients did not respond to treatment. One patient with chronic paroxysmal hemicrania experienced pain relief of the acute attack after treatment, but the procedure did not abort the subsequent attacks. A surgical sympathectomy removing the stellate ganglion rendered him pain-free for 15 months after which he was lost to follow-up. CONCLUSION: Blocking the sympathetic nerve aborts an acute attack of cluster headache and may play a major role in aborting the cluster. Although only one patient with chronic paroxysmal hemicrania responded to surgical sympathectomy, this procedure may be considered as an alternative if there is poor response to oral medication or a sympathetic block.

Medication overuse headache.

Medication overuse headache may complicate any type of headache and occurs in young people, adults, and even elderly patients.Overuse of acute medications may change intermittent or self-limited headaches into chronic daily headache. Migraineurs seem particularly prone to analgesic rebound headache/ transformed migraine/chronic migraine. Prophylactic therapies are often ineffective in the setting of medication overuse. Recognition of this condition allows appropriate clinical intervention that includes cessation of the offending medications.

Subcutaneous sumatriptan induces changes in frequency pattern in cluster headache patients.

OBJECTIVES: To document the relationship between the use of subcutaneous (SQ) sumatriptan (sum) and a change in frequency pattern of cluster headache (CH) in six patients. To discuss the clinical and pathophysiological implications of this observation in the context of available literature. BACKGROUND: Treatment with SQ sum may cause an increase in attack frequency of CH but data from literature are scant and controversial. methods: Six CH sum-naive patients (three episodic and three chronic according to the International Headache Society (IHS) criteria) are described. RESULTS: All six patients had very fast relief from pain and accompanying symptoms from the drug but they developed an increase in attack frequency soon after using SQ sum. In all patients, the CH returned to its usual frequency within a few days after SQ sum was withdrawn or replaced with other drugs. Five patients were not taking any prophylactic treatment and SQ sum was the only drug prescribed to treat their headache. CONCLUSIONS: physicians should recognize the possibility that treatment of CH with SQ sum may be associated with an increased frequency of headache attacks.

Hypothalamic activation in trigeminal autonomic cephalgia: functional imaging of an atypical case.

We report headache induced BOLD changes in an atypical case of trigeminal autonomic cephalgia (TAC). A 68-year-old patient was imaged using fMRI during three attacks of a periorbital head-pain with a average duration of 3 min. During the attacks, left sided conjunctival injection, rhinorrhea, lacrimation, facial sweating and hypersalivation were apparent. These attacks were usually partly responsive to oxygen administration but otherwise refractory to any drug. The patient described either attacks with a duration of one minute or less or longer attacks persisting for maximum of 20 min with headaches occurring up to 100 times a day. When considering the symptoms, frequency, duration and therapeutic response of the patient's headache, no clear-cut classification to one of the subtypes of trigeminal autonomic cephalgias (cluster headache, paroxysmal hemicrania, SUNCT) or trigeminal neuralgia was possible. The cerebral activation pattern was similar but not identical to those previously observed in cluster headache and SUNCT with a prominent activation in the hypothalamic grey matter. This case study underlines the conceptual value of the term TAC for the group of headaches focusing around the trigeminal-autonomic reflex. Our results emphasize the importance of the hypothalamus as key region in the pathophysiology of this entity.

Long-term follow-up of bilateral hypothalamic stimulation for intractable cluster headache.

We provide a detailed case history of the first patient to receive bilateral hypothalamic stimulation to control severe bilateral chronic intractable cluster headaches initially occurring mostly on the left. These attacks were accompanied by life-threatening hypertensive crises and a grave deterioration in the patient's psychological state. Destructive surgery to the left trigeminal was absolutely contraindicated. Electrode implantation and continuous stimulation of the left posterior inferior hypothalamus resolved the left attacks. After four destructive operations on the right trigeminal, right side attacks recurred. Electrode implantation (with continuous stimulation) to the right resulted in immediate resolution of the right side pain and the hypertensive crises. On several occasions, both known and unknown to the patient, the stimulators were turned off: in all cases, crises reappeared and in all instances disappeared relatively quickly after turning stimulation back on. pain crises have never reappeared when ipsilateral stimulation is ongoing. The only side effects were observed during long-term bilateral stimulation, consisting of transient vertigo and bradycardia. After 42 months (left) and 31 months (right) of follow-up, the patient remains crisis free without the need for pharmacological prophylaxis.

Complete but transient relief of chronic cluster headache with mycophenolate mofetil.

Chronic cluster headache is one of the most disabling of all neurologic conditions. New effective therapies for refractory chronic cluster headache are needed. The unique sensitivity of most cluster headache patients to corticosteroid treatment suggests that steroid-sparing immunosuppressive drugs may show benefit as cluster headache preventives. A patient is presented who had complete but transient relief of chronic cluster headache with mycophenolate mofetil.

Long-term effects of octreotide on pituitary gigantism: its analgesic action on cluster headache.

We report the case of 19-year-old man with pituitary gigantism due to growth hormone-producing pituitary macroadenoma. The patient complained of recurrent headache and excessive growth spurt since age 15. octreotide administration was initiated following transsphenoidal pituitary adenomectomy. octreotide injection for 4 years efficaciously reduced the size of remnant adenoma as well as serum growth hormone levels. Notably, octreotide exhibited a potent analgesic effect on his intractable cluster headache that has continued even after reduction of the adenoma volume. The analgesic effect lasted 2 to 6 hours after each injection and no tachyphylaxis to octreotide appeared during 4-year treatment. To characterize the headache and the pain intensity, analgesic drugs including octreotide, lidocaine, morphine and thiopental were tested using a visual analogue scale (VAS) evaluation, with the result that octreotide exhibited a prompt and complete disappearance of the headache. Headache relief was in part reproduced by morphine injection (56% reduction) but not by lidocaine or thiopental. The present case suggests that the intractable headache associated with pituitary gigantism is possibly related to the endogenous opioid system. Thus, the headache control by octreotide is clinically helpful for continuation of the self-injection regimen.

Asystole associated with cluster headache.

A 43-year-old man with asystole and syncope occurring during cluster headache attacks is reported. The asystole and syncope attacks disappeared completely following prophylactic therapy with methysergide maleate. To the authors' knowledge, the present case is unique in associating asystole with cluster headache attacks and may be due to hyperactivity of the parasympathetic system.
verapamil induced gingival enlargement in cluster headache.
verapamil is an effective prophylactic treatment for cluster headaches and, therefore, is widely used. This report describes four patients with cluster headache who developed gingival enlargement after initiating treatment with verapamil. In two patients, it was possible to control this side effect adequately by optimising oral hygiene and dental plaque control. In the other two patients, lowering of the verapamil dose, in addition to optimal oral hygiene and dental plaque control, was necessary; in one patient verapamil had to be stopped completely to reverse the gingival enlargement. Doctors treating cluster headache with verapamil need to be aware of this side effect, especially as it may be preventable with good dental hygiene and dental plaque control, is reversible with reduction or cessation of verapamil, and can lead to dental loss.

Familial cluster headache: occurrence in three generations.

We report the occurrence of cluster headache in three generations of one family: an 8-year-old boy with primary chronic cluster headache, his 42-year-old father with secondary chronic cluster headache, and his 73-year-old paternal grandfather with episodic cluster headache.

cluster headache: alterations in heart rate, blood pressure and orthostatic responses during spontaneous attacks.

Changes in heart rate and blood pressure (BP) have been monitored beat-to-beat in a cluster headache patient with and without attacks using a non-invasive Doppler servo method. Two attacks were monitored and during one of them a tilt test was carried out. The variability of heart rate and BP was greater during the attack than during the interparoxysmal period. A marked bradycardia occurred during attacks. Systolic BP increased slightly. There was no heart rate increase after tilting during the attack, whereas this was present invariably during tests carried out interparoxysmally. BP changes during "attack tilt" were difficult to evaluate because of large variation. This may be the first observation of a baroreflex arc dysfunction during a cluster headache attack.

Non-hypothalamic cluster headache: the role of the greater occipital nerve in cluster headache pathogenesis.

cluster headache is marked by its circadian rhythmicity and the hypothalamus appears to have a significant influence over cluster pathogenesis. However, as not all cluster patients present in the same manner and not all respond to the same combination of medications, there is likely a nonhypothalamic form of cluster headache. A patient is presented who began to develop cluster headaches after receiving bilateral greater occipital nerve (GON) blockade. His headaches fit the IHS criteria for cluster headache but had some irregularities including frequent side shifting of pain, irregular duration and time of onset and the ability of the patient to sit completely still during a headache without any sense of agitation. This article will suggest that some forms of cluster headache are not primarily hypothalamic influenced and that the GON may play a significant role in cluster pathogenesis in some individuals.

A case of myocardial infarction with sumatriptan use.

sumatriptan is widely used in the treatment of acute attacks of cluster headache. It is a serotonin-1 (5HT-1) agonist. Several studies have reported an association between sumatriptan use and myocardial infarction, possibly due to the generalized vasoconstrictive nature of this agent. We report a 16-year-old male patient presenting with acute inferior myocardial infarction after sumatriptan use without any known risk factors of coronary artery disease.

A sleep study in cluster headache.

cluster headache (CH) is a primary headache with a close relation to sleep. CH presents a circa-annual rhythmicity; attacks occur preferably during the night, in rapid eye movement (REM) sleep, and they are associated with autonomic and neuroendocrine modifications. The posterior hypothalamus is the key structure for the biological phenomenon of CH. Our aim is to describe a 55-year-old man presenting a typical episodic CH, in whom we performed a prolonged sleep study, consisting of a 9-week actigraphic recording and repeated polysomnography, with evaluation of both sleep macrostructure and microstructure. During the acute bout of the cluster we observed an irregular sleep-wake pattern and abnormalities of REM sleep. After the cluster phase these alterations remitted. We conclude that CH was associated, in this patient, with sleep dysregulation involving the biological clock and the arousal mechanisms, particularly in REM. All these abnormalities are consistent with posterior hypothalamic dysfunction.

Great occipital nerve blockade for cluster headache in the emergency department: case report.

A 44-year-old man with a past medical history of episodic cluster headache presented in our ED with complaints of multiple daily cluster headache attacks, with cervico-occipital spreading of pain from May to September 2004. The neurological examination showed no abnormalities as well as brain and spine MRI. Great Occipital Nerve (GON) blockade, with lidocaine 2% (5 ml) and betamethasone (2 mg), were performed in the right occipital region (ipsilaterally to cluster headache), during attack. GON blockade was effective immediately for the attack and the cluster period resolved after the injection. We suppose that the action of GON blockade may involve the trigemino-cervical complex and we moreover strongly suggest to use GON blockade in emergency departments for cluster headache with cervico-occipital spreading as attack abortive therapy, especially in oxygen and sumatriptan resistant cluster headache attacks, in patients who complaints sumatriptan side-effects or have contraindications to use triptans.

testosterone replacement therapy for treatment refractory cluster headache.

OBJECTIVES: To describe the clinical characteristics and laboratory findings of cluster headache patients whose headaches responded to testosterone replacement therapy. BACKGROUND: Current evidence points to hypothalamic dysfunction, with increased metabolic hyperactivity in the region of the suprachiasmatic nucleus, as being important in the genesis of cluster headaches. This is clinically borne out in the circadian and diurnal behavior of these headaches. For years it has been recognized that male cluster headache patients appear overmasculinized. Recent neuroendocrine and sleep studies now point to an association between gonadotropin and corticotropin levels and hypothalamically entrained pineal secretion of melatonin. RESULTS: Seven male and 2 female patients, seen between July 2004 and February 2005, and between the ages of 32 and 56, are reported with histories of treatment resistant cluster headaches accompanied by borderline low or low serum testosterone levels. The patients failed to respond to individually tailored medical regimens, including melatonin doses of 12 mg a day or higher, high flow oxygen, maximally tolerated verapamil, antiepileptic agents, and parenteral serotonin agonists. Seven of the 9 patients met 2004 International classification for the diagnosis of Headache criteria for chronic cluster headaches; the other 2 patients had episodic cluster headaches of several months duration. After neurological and physical examination all patients had laboratory investigations including fasting lipid panel, PSA (where indicated), LH, FSH, and testosterone levels (both free and total). All 9 patients demonstrated either abnormally low or low, normal testosterone levels. After supplementation with either pure testosterone in 5 of 7 male patients or combination testosterone/estrogen therapy in both female patients, the patients achieved cluster headache freedom for the first 24 hours. Four male chronic cluster patients, all with abnormally low testosterone levels, achieved remission. CONCLUSIONS: Abnormal testosterone levels in patients with episodic or chronic cluster headaches refractory to maximal medical management may predict a therapeutic response to testosterone replacement therapy. In the described cases, diurnal variation of attacks, a seasonal cluster pattern, and previous, transient responsiveness to melatonin therapy pointed to the hypothalamus as the site of neurological dysfunction. prospective studies pairing hormone levels and polysomnographic data are needed.

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