• Home

Home > Medical Reference > Patient Education

• Highlights
• Introduction
• Cluster Headaches
• Causes
• Prognosis
• Risk Factors
• Diagnosis
• Managing Cluster Headaches
• Treatment for Acute Attacks
• Preventive Medications
• Surgery
• Resources
• References

Headaches - cluster

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of cluster headaches.

Preventive Medications

Calcium-Channel Blockers

Calcium-channel blockers, commonly used to treat heart disease, are important drugs for preventing cluster headaches. Verapamil (Calan) is the standard calcium-channel blocker used for headache prevention. Constipation is a common side effect. No one taking any calcium-channel blocker should withdraw the drug abruptly, because this can dangerously increase blood pressure. Overdose can cause dangerously low blood pressure and slow heart beats. Drinking grapefruit juice or eating grapefruit with these drugs can enhance their potency, sometimes to toxic levels that can cause heart failure in patients with heart disease.

Lithium

Lithium (Eskalith, Lithane, Lithobid, Lethonate, Lithotabs), commonly used for bipolar disorder, can also help prevent cluster headaches. The patient usually experiences benefits within 2 weeks, and often within the first week. Lithium may be used alone or with other drugs.

Side Effects. Side effects include:

• Trembling hands
• Nausea
• Increased urine output
• Some loss of coordination

More severe reactions, which occur at higher blood levels, are:

• Convulsions
• Uncontrolled jerky movements in arms and legs
• Blurred vision
• Vomiting
• Stupor
• Coma

Very high blood levels of lithium can be fatal.

If toxicity occurs, drugs should be stopped immediately and one or more of the following steps taken, depending on severity:

• Patients are given fluids and drugs to increase excretion of lithium salts.
• Gastric lavage, a procedure that rinses the stomach may be used to treat very recent overdoses.
• Hemodialysis, a procedure that filters lithium out of the blood, may also be performed in severe cases.

Long-Term Side Effects. Even for patients who do not experience a toxic response, long-term use of lithium is not without problems. Some patients may experience:

• An unpleasant taste in the mouth
• Hair loss
• Weight gain (a frequent reason why many patients stop taking lithium)
• Skin eruptions that can resemble acne (lithium can also worsen psoriasis in patients who have this condition)
• Thyroid problems -- Up to 20% of patients who take lithium develop symptomatic hypothyroidism (low thyroid), and another 20 - 30% develop hypothyroidism without symptoms.
• Increased risk for diabetes
• Blunted sexual drive
• Dulled emotions and mental acuity
• Memory loss
• Lack of motor coordination
• Reduced sensitivity to light -- This may slightly affect color recognition and cause problems with night driving; patients wear sunglasses outside and avoid extensive exposure to bright light.

Drug Interactions. Because lithium is eliminated from the body by the kidneys, any drugs or dietary factors that slow the kidneys' actions may increase lithium blood levels and should be used with great caution. Such drugs include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Thiazide diuretics
• ACE inhibitors

There have been reports of interactions between lithium and certain drugs commonly used in combination, including:

• Antipsychotics
• Anticonvulsants
• Calcium-channel blockers

Other Factors That Affect Lithium Levels. In addition to drugs, other factors may affect lithium levels, including:

• Seasonal change
• Menstrual cycle (lithium levels may drop during the premenstrual phase)
• Weight loss
• Changes in salt intake
• Dehydration
• Diarrhea

Patients should be sure to contact their doctor if they have any suspicious symptoms or illnesses.

Valproate and Other Anti-Seizure Drugs

Valproate. The anti-epileptic drug valproate (valproic acid, divalproex sodium, Depakene, Depakote) has been used with some success for preventing cluster headaches. It controls pain and reduces the frequency of attacks by more than half in many people with episodic or chronic cluster headaches. Side effects include nausea, vomiting, heartburn, increased appetite with weight gain, hand tremors, irritability, and temporary hair thinning and loss (taking zinc and selenium supplements may help reduce this effect). It can also cause birth defects and, in rare cases, liver toxicity.

Topiramate. Other, newer anti-seizure drugs that have fewer side effects are being investigated for chronic headaches. Studies on topiramate (Topamax) are promising. In small trials of topiramate, up to 87% of patients achieved remission, and 60% achieved a complete response. Still, about 25% of patients stop using it, either because it doesn't work or because the side effects are intolerable. They can include drowsiness, mood changes, tremor, and confusion.

Gabapentin . Another anti-seizure drug that has shown some benefit in isolated cases is gabapentin (Neurontin). Research on this drug in patients with cluster headaches, however, remains very limited.

Side Effects of Valproate and Other Anti-Seizure Drugs. The side effects given here are mostly associated with valproate. Other anti-seizure drugs have similar effects and some specific ones of their own. Most are usually minor, occurring early in therapy, and then subsiding. Those of valproate include:

• Gastrointestinal problems (nausea, vomiting, heartburn)
• Visual disturbances
• Ringing in the ear
• Hair loss
• Weight changes (weight gain is a significant problem with valproate, while weight loss occurs with topiramate)
• Agitation
• Odd movements
• In women, menstrual irregularities and a higher risk for polycystic ovary syndrome (PCOS)

Very serious side effects are rare but include the following:

• Liver damage
• Convulsions
• Coma
• Pancreatitis (inflammation of pancreas) in adults and children
• Significant increase in risk for birth defects in pregnant women

Capsaicin

A nasal spray form of capsaicin called civamide (Zucapsaicin) has shown promise in the prevention and treatment of cluster headaches. Capsaicin is a component of hot red peppers that seems to reduce substance P, a chemical in the body that contributes to inflammation and the delivery of pain impulses. In a small 2002 study, daily use of intranasal civamide resulted in more than a 50% reduction in headaches. Side effects include a burning sensation and excessive tearing.

Transitional Drugs

Certain medications are useful as transitional drugs. These medications are used after cluster episodes to stabilize the patient until preventive maintenance becomes effective.

Methysergide. Methysergide (Sansert) is also used for preventing episodic cluster headaches. (It is not very effective for chronic cluster headaches.) Improvement usually occurs within a few days, although it may be delayed for up to 2 weeks. Prolonged methysergide therapy can cause serious side effects, including scarring of internal organs, so it cannot be used long term. This is not usually a problem for patients with cluster headaches, since they only require the drug for about 4 - 6 weeks. Nevertheless, patients should immediately report to their doctors any of the following symptoms: cold, numb, and painful hands and feet; leg cramps on walking; any type of back or chest pain.

Ergotamine. Drugs containing ergotamine (sometimes called ergots) cause contractions of smooth muscles, including those in blood vessels, and are commonly used for migraine. Taking them before an expected cluster attack produces good results for many patients. One ergot-derived drug called dihydroergotamine (DHE) is administered by injection, which can be performed by the patient at home. It is also available as a nasal spray (Migranal), which may have fewer side effects than the injection. Ergotamine itself is available in oral tablets (Ergomar, Wigraine, Ercaf) and in rectal suppositories (Cafergot). Cafergot, Wigraine, and Ercaf contain caffeine. An ergotamine inhaler is being investigated.

Side effects of ergotamine include nausea, dizziness, tingling sensations, muscle cramps, and chest or abdominal pain. Ergotamine has toxic effects at high levels. It also causes persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke. Pregnant women, people over age 60, and those with serious, chronic health problems, particularly those of the heart and circulation, should avoid these medications altogether. As with other migraine drugs, if ergotamine is taken more than twice a week, the patient is at risk for rebound headaches when the drug is withdrawn, although cluster headaches appear to be at lower risk for this effect than other types of headaches.

Corticosteroids. A corticosteroid is very useful as a transitional drug for stabilizing patients after an attack until a maintenance drug, such as a calcium-channel blocker, begins to take effect. The corticosteroid drug prednisone is effective in up to 90% of patients with episodic cluster headaches. The drug is typically taken for a week and then gradually tapered off. If headaches return, then it may be administered again. Unfortunately, long-term use of steroids can lead to serious side effects so they cannot be taken for on-going prevention.

Other Drugs Investigated for Prevention

Baclofen (Lioresal). Baclofen is a drug that relaxes muscle spasms. Small studies have reported some success. For example, in a 2001 study, 12 of 16 patients reported an end of attacks within a week and another one became headache-free by the second week. (The remaining three patients became worse, however, and required other drugs.) Three of the patients who improved experienced an additional cluster cycle, which cleared when they took another course of baclofen.

Botulinum. Botulinum toxin A (Botox) injections are being used for several conditions requiring muscle relaxation, including smoothing wrinkles. (This potentially deadly toxin is very safe when minuscule amounts are injected into small muscles.) Botox has shown promise for migraine and tension headache sufferers and is now being studied for cluster headaches as well. It is too early yet to gauge any real benefits.

Alternative Therapies

Melatonin. Small reports indicate that melatonin, a brain hormone that helps to regulate the sleep-wake cycle, may help prevent episodic or chronic cluster headaches. Melatonin supplements are sold in health food stories, but as with most natural remedies, the quality of different preparations varies, and they have not been rigorously tested for safety or effectiveness. Hormones such as melatonin are powerful substances, and additional studies are needed.

Glucosamine. There have been some reports that glucosamine, an alternative remedy commonly used for osteoarthritis, may prevent migraine attacks. Some researchers theorize this substance may reduce inflammation that affects nerves involved in vascular headaches. Whether it has any effect on cluster headaches is unknown.

Additional Therapies. Many patients with cluster headaches try alternative remedies for relief of pain. Treatments may include acupuncture, herbs, chiropractic, homeopathic remedies, reflexology, hypnosis, spiritual therapies, massage, aromatherapy, relaxation techniques, and yoga. A 2002 survey of patients attending a headache clinic or support groups, however, did not find any of these alternative therapies to be consistently effective.

• Review Date: 10/19/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is the first of its kind, requiring compliance with 53 standards of quality and accountability, verified by independent audit. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial process . A.D.A.M. is also a founding member of Hi-Ethics (www.hiethics.com) and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2007 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.