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Cluster HeadacheThe surgical management of chronic cluster headache. Lovely TJ, Kotsiakis X, Jannetta PJ. Department of Neurological Surgery, University of Pittsburgh (Penn) School of Medicine, USA. OBJECTIVE: Chronic cluster headache occurs in less than 10% of cluster headache sufferers, but remains an intractable medical problem. Surgical treatments have also been limited in their effectiveness. The authors describe their experience with attempted surgical amelioration of chronic cluster headache. DESIGN: Twenty-eight patients, including two with bilateral cluster headache, underwent 39 operations for microvascular decompression of the trigeminal nerve, alone or in combination with section and/or microvascular decompression of the nervus intermedius. Follow-up averaged 5.3 years. RESULTS: Initial postoperative success described as 50% relief or greater was achieved in 22 (73.3%) of 30 first-time procedures and greater than 90% relief in half (15 of 30) of these. Long-term follow-up saw this success rate (excellent or good) drop to 46.6%. Repeat procedures have little success, with 7 of 8 failing at long-term follow-up. Morbidity and neurological deficit from the operations was minimal. CONCLUSIONS: Chronic cluster headache remains a debilitating and poorly controlled syndrome. Although various surgical treatments have had limited success, microvascular decompression of the trigeminal nerve with section of the nervus intermedius compares very favorably to other destructive techniques without the accompanying neurologic deficits. It is, therefore, our recommendation as the first-line operative treatment of chronic cluster headache. Aspects on the pathophysiology of migraine and cluster headache. Edvinsson L. Department of Internal Medicine, Lund University Hospital, Lund, Sweden. The specific cause of migraine headache remains unknown. Current theories suggest that the initiation of a migraine attack involves a primary CNS dysfunction with subsequent activation of the trigeminovascular system. Studies in patients have revealed a clear association between headache and the release of the neuropeptide calcitonin gene-related peptide, probably from C fibres. In cluster headache and in a case of chronic paroxysmal headache there was in addition release of the parasympathetic neuropeptide vasoactive intestinal peptide, which was associated with headache, nasal congestion and rhinorrhea. Triptan administration, activating the 5-HT1B/1D receptors, caused the headache to subside and the neuropeptide release to normalise. These data suggest the involvement of sensory and parasympathetic mechanisms in the pathophysiology of primary headaches. Behavioral and nonpharmacologic treatments of headache. Lake AE 3rd. Michigan Head-Pain and Neurological Institute, Ann Arbor, Michigan, USA. aelake3rd@aol.com Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol. Cluster headache responds poorly to behavioral treatment. The persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. Behavioral treatment can help sustain improvement after analgesic withdrawal, however, and prevent relapse in cases of analgesic overuse. Cognitive factors (e.g., an enhanced sense of self-efficacy and internal locus of control) appear to be important mediators of successful behavioral treatment. Patients with CDH are more likely to overuse symptomatic medication (and in some cases abuse analgesics), have more psychiatric comorbidity; have more functional impairment and disability, and are at least as likely to experience stress-related intensification of headache as patients whose episodic headaches occur less than 15 days per month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache. 1: Reg Anesth Pain Med 2001 Jul;26(4):373-375 Related Articles, Books, LinkOut Gabapentin for the treatment and prophylaxis of cluster headache. Tay BA, Ngan Kee WD, Chung DC. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China. BACKGROUND AND OBJECTIVES: Cluster headache is an uncommon debilitating condition for which effective management remains a challenge. We describe the use of gabapentin in the treatment and prophylaxis of cluster headache in a patient who was refractory to other treatments. Case Report: A 38-year-old man had a history of intermittent right-side headaches for 24 years, diagnosed as cluster headache. He received only partial relief from a range of conventional treatments. A trial with gabapentin 300 mg twice daily was tried and found to be effective in treatment and prophylaxis of his headaches. CONCLUSION: Gabapentin was effective in the treatment of a patient with cluster headache. Further investigation of gabapentin compared with conventional treatments and placebo is warranted. Reg Anesth Pain Med 2001;26:373-375. PMID: 11464360 [PubMed - in process] The surgical management of chronic cluster headache. Lovely TJ, Kotsiakis X, Jannetta PJ. Department of Neurological Surgery, University of Pittsburgh (Penn) School of Medicine, USA. OBJECTIVE: Chronic cluster headache occurs in less than 10% of cluster headache sufferers, but remains an intractable medical problem. Surgical treatments have also been limited in their effectiveness. The authors describe their experience with attempted surgical amelioration of chronic cluster headache. DESIGN: Twenty-eight patients, including two with bilateral cluster headache, underwent 39 operations for microvascular decompression of the trigeminal nerve, alone or in combination with section and/or microvascular decompression of the nervus intermedius. Follow-up averaged 5.3 years. RESULTS: Initial postoperative success described as 50% relief or greater was achieved in 22 (73.3%) of 30 first-time procedures and greater than 90% relief in half (15 of 30) of these. Long-term follow-up saw this success rate (excellent or good) drop to 46.6%. Repeat procedures have little success, with 7 of 8 failing at long-term follow-up. Morbidity and neurological deficit from the operations was minimal. CONCLUSIONS: Chronic cluster headache remains a debilitating and poorly controlled syndrome. Although various surgical treatments have had limited success, microvascular decompression of the trigeminal nerve with section of the nervus intermedius compares very favorably to other destructive techniques without the accompanying neurologic deficits. It is, therefore, our recommendation as the first-line operative treatment of chronic cluster headache. 1: Med Clin North Am 2001 Jul;85(4):1055-1075 Related Articles, Books, LinkOut Aspects on the pathophysiology of migraine and cluster headache. Edvinsson L. Department of Internal Medicine, Lund University Hospital, Lund, Sweden. The specific cause of migraine headache remains unknown. Current theories suggest that the initiation of a migraine attack involves a primary CNS dysfunction with subsequent activation of the trigeminovascular system. Studies in patients have revealed a clear association between headache and the release of the neuropeptide calcitonin gene-related peptide, probably from C fibres. In cluster headache and in a case of chronic paroxysmal headache there was in addition release of the parasympathetic neuropeptide vasoactive intestinal peptide, which was associated with headache, nasal congestion and rhinorrhea. Triptan administration, activating the 5-HT1B/1D receptors, caused the headache to subside and the neuropeptide release to normalise. These data suggest the involvement of sensory and parasympathetic mechanisms in the pathophysiology of primary headaches. PMID: 11555322 [PubMed - in process] Behavioral and nonpharmacologic treatments of headache. Lake AE 3rd. Michigan Head-Pain and Neurological Institute, Ann Arbor, Michigan, USA. aelake3rd@aol.com Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol. Cluster headache responds poorly to behavioral treatment. The persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. Behavioral treatment can help sustain improvement after analgesic withdrawal, however, and prevent relapse in cases of analgesic overuse. Cognitive factors (e.g., an enhanced sense of self-efficacy and internal locus of control) appear to be important mediators of successful behavioral treatment. Patients with CDH are more likely to overuse symptomatic medication (and in some cases abuse analgesics), have more psychiatric comorbidity; have more functional impairment and disability, and are at least as likely to experience stress-related intensification of headache as patients whose episodic headaches occur less than 15 days per month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache. Publication Types: Review Review, tutorial PMID: 11480258 [PubMed - indexed for MEDLINE] 1: Reg Anesth Pain Med 2001 Jul;26(4):373-375 Related Articles, Books, LinkOut Gabapentin for the treatment and prophylaxis of cluster headache. Tay BA, Ngan Kee WD, Chung DC. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China. BACKGROUND AND OBJECTIVES: Cluster headache is an uncommon debilitating condition for which effective management remains a challenge. We describe the use of gabapentin in the treatment and prophylaxis of cluster headache in a patient who was refractory to other treatments. Case Report: A 38-year-old man had a history of intermittent right-side headaches for 24 years, diagnosed as cluster headache. He received only partial relief from a range of conventional treatments. A trial with gabapentin 300 mg twice daily was tried and found to be effective in treatment and prophylaxis of his headaches. CONCLUSION: Gabapentin was effective in the treatment of a patient with cluster headache. Further investigation of gabapentin compared with conventional treatments and placebo is warranted. Reg Anesth Pain Med 2001;26:373-375. PMID: 11464360 [PubMed - in process] |