Pain Conditions
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      Chronic Cluster Headaches

      Brief Overview: Cluster headache is a primary headache disorder characterized by recurrent, severe unilateral attacks of head pain with associated autonomic symptoms (tearing, nasal congestion, eyelid drooping).

      • Chronic Cluster Headaches: According to UpToDate, “Patients with the chronic form of cluster headache report either continual attacks (persisting bout) or report brief remissions of less than three months. Chronic cluster headache may arise de novo or evolve both from and to the episodic type. Cluster headache is considered chronic once a bout persists for a year without remission.”
      • Known as the “suicide headache” due to severity of pain.

      Prevalence: According to UpToDate, “The prevalence of cluster headache is <1 percent.”

      Etiology:

      • Exact cause not fully understood.
      • Believed to involve:
        • Hypothalamic dysfunction → circadian rhythm disturbance.
        • Abnormal activity in the trigeminal autonomic reflex pathway.
      • Possible roles of genetics, vascular, and environmental triggers.

      Risk Factors:

      • Male
      • 20-40 years old, >80 years old
      • Genetics/family history
      • Tobacco use
      • Headache trauma
      • Depression
      • Risk-taking behaviors

      Commonly Associated Conditions:

      • Depression, anxiety, suicidality (due to pain severity)
      • Sleep disorders
      • Substance use (tobacco, alcohol)
      • Other headache disorders (though cluster headache is distinctive)

      Common Medications:

      • Acute treatment:
        • 100% oxygen
        • Triptans – sumatriptan, zolmitriptan
        • Intranasal lidocaine
        • Oral ergotamine
        • IV dihydroergotamine
      • Preventive treatment:
        • Verapamil
        • Glucocorticoids
        • Oral ergotamine
        • Topiramate

      Common Labs, Imaging, and Tests:

      • Brain MRI
      • Heat CT – alternative to MRI

      Common Symptoms:

      • Per UpToDate, “Cluster headaches are severe and sharp or stabbing in quality. Patients are typically restless and often prefer to pace about or sit and rock back and forth during a cluster headache attack. Some patients may report cutaneous allodynia [31]. Symptoms most commonly occur in periorbital or temporal regions. Cluster headache attacks are strictly unilateral, and the symptoms almost always remain on the same side of the head during a single attack. However, the symptoms can switch to the other side during a different cluster attack (so-called side shift) in approximately 15 percent of cases [32]. A typical attack persists for 15 minutes up to three hours in duration and may strike from once every other day to up to eight times a day. These frequently recurring attacks occur in a cluster or bout and are separated by periods of remission, often for months, when patients are asymptomatic.”
      • Symptoms during acute attacks: ptosis, eyelid swelling, miosis, conjunctival injection, eye tearing, nasal congestion, rhinorrhea, hemifacial sweating

      Common Treatments:

      • Greater occipital nerve block
      • Botox injections may have some benefit

      Physical Findings:

      • Autonomic signs during an attack:
        • Red, watery eye
        • Nasal congestion
        • Ptosis (drooping eyelid) or miosis (constricted pupil)
      • Physical exam is usually normal between attacks.

      Potential Complications and Contraindications:

      • Severe disability, reduced quality of life
      • High rates of depression, anxiety, and suicide risk
      • Misdiagnosis leading to inappropriate treatment

      General Health and Lifestyle Guidance:

      • Avoid alcohol during active cluster periods
      • Stop smoking (strong association with cluster headaches)
      • Maintain regular sleep patterns
      • Identify and avoid individual triggers if possible
      • Stress management (mindfulness, relaxation)
      • Encourage adherence to preventive meds and follow-up with neurology

      Suggested Questions to Ask Patients:

      • How often do your headaches occur, and how long do they last?
      • What do you do during an attack — do you lie down, or feel restless?
      • Have you noticed eye watering, nasal congestion, or eyelid drooping with attacks?
      • What medications are you currently using, and how often?
      • Do you use oxygen or triptans at the start of attacks?
      • Do you drink alcohol or smoke? Do you notice if they trigger attacks?
      • How do the headaches affect your daily life, sleep, or mood?
      • Have you ever had thoughts of self-harm due to the pain? – need to make sure CCs know how to respond if the patient answers “yes” to this

      Suggested Talking Points:

      • Cluster headaches are very painful but can be treatable — oxygen and certain medications can give relief.
      • Preventive medications can reduce how often headaches occur.
      • It’s important to use your oxygen or triptan as soon as a headache starts. Follow your treatment plan as directed by your healthcare provider.
      • Ask your healthcare provider what symptoms to watch for and when to seek urgent/emergency care.
      • Avoiding alcohol and smoking can reduce attack severity.
      • Because these headaches are so severe, it’s normal to feel down or hopeless — please let us know if you ever feel overwhelmed so we can support you. – Advise to call 911 or crisis line if needed.

      Sources:

      This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.