Getting to know the symptoms and treatment options for cluster headache
Cluster headache is a relatively rare type of headache. People typically experience short, incapacitating attacks that present on one side of the head around the eye, forehead and temple, says Dr. Stewart Tepper, a professor of neurology at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire. Dr. Tepper recently spoke with the American Migraine Foundation about the causes of cluster headache, the various physical symptoms, treatment options and ongoing research. Read on below.
What is Cluster Headache?
“We call cluster headache a primary headache in that it’s not due to other disorders,” Dr. Tepper says. People can experience cluster headache in a variety of ways. These headache attacks most often occur one to three times a day. Unlike other types of migraine or disorders that cause severe headache, patients experiencing an attack do not seek relief in a dark, quiet room. “Instead, they run around, rock their bodies and are usually very agitated,” says Dr. Tepper. Cluster headache also differs from migraine in that it is particularly common in men, especially middle-aged men who are smokers.
The most common types of cluster headache are episodic cluster headache, in which people experience daily attacks for a period of time before stopping abruptly, and chronic cluster, in which people experience regular daily attacks without a period of relief. “We don’t know the actual cause of cluster headache, but we do know the anatomy behind it,” Dr. Tepper says. Cluster headache generally develops in the area of the brain called the hypothalamus, which also controls our circadian rhythm.
People living with cluster headache typically have cranial autonomic symptoms, which occur on the side of the face with head pain. According to Dr. Tepper, these symptoms include the following on the same side as the headache:
- Sweating or swelling of the face
- Red or droopy eye
- Small pupil
- Tearing from the eye
- Runny or stuffy nose
Current Treatment Options
Dr. Tepper has one very important piece of advice for patients living with cluster headache: Get to a headache specialist. “Most cluster patients we can treat,” he says. A headache specialist can help you determine the best course of treatment for your symptoms and your lifestyle.
When it comes to evaluating the best treatment for you, consider both transitional treatments and acute treatments. Transitional therapies, which typically consist of oral steroids or injections of occipital nerves with an anesthetic and a steroid, can provide patients with up to a week or two of relief. Headache specialists typically administer these treatments while incorporating preventive treatments such as daily oral verapamil.
“We can also treat cluster headache on an acute or as-needed basis,” says Dr. Tepper. “This is important because every single attack needs to be treated.” Two FDA-approved medications for terminating cluster headache are currently available: sumatriptan and injectable dihydroergotamine (DHE). However, Dr. Tepper says, one of the most, if not the most, effective treatment options is oxygen. “We recommend patients breathe through a non-rebreathing mask at a high rate of oxygen flow,” he says. “Generally, around 80 percent of attacks can be terminated by oxygen within 20 minutes.”
In addition, the FDA has approved a portable device without significant side effects—the non-invasive vagal nerve stimulator—for the acute treatment of episodic cluster headache attacks. A person turns on the device and holds it to the neck for three cycles of two minutes at the start of an attack. This device is now commercially available with a prescription. It was not found effective in terminating chronic cluster headache attacks.
“There’s never been a more hopeful time for cluster patients than right now,” says Dr. Tepper. “The hope is that in three or four years our treatment will be vastly improved for cluster.”
New treatment options are the horizon. Calcitonin gene-related people, or CGRP, is a chemical that is associated with causing migraine and cluster headache. Currently, a number of companies are developing antibodies to either CGRP or the CGRP receptor. One of these anti-CGRP monoclonal antibodies, galcanezumab, was found to prevent episodic cluster headache and is expected to be submitted to the FDA for this prevention soon. Another monoclonal antibody, fremanezumab, is being tested for this disorder. Unfortunately, neither of these medications worked to prevent chronic cluster headache, says. Dr. Tepper.
However, the good news is that a device that is implanted through the mouth, a sphenopalatine ganglion (SPG) stimulator, has been found to be effective in treating chronic cluster headache attacks. Several studies also reported that the device can also prevent chronic cluster headaches. This device is approved and commercially available in Europe. It is currently before the FDA for approval in the U.S., and would be the first acute treatment for chronic cluster headache attacks.
The American Migraine Foundation has an extensive collection of information on cluster headache and other disorders that cause severe headache in our resource library. Use our Find a Doctor tool to locate a headache specialist in your area, and discover your support community by joining the Move Against Migraine Facebook Group.