Latest treatments for cluster headaches and tension


In an article published in the May issue of JAMA, MS Robbins, of Weill Cornell Medical College, reviews the diagnosis, prevention, and treatment of primary headaches.

In a previous article, I talked about migraines, especially the latest medical interventions to prevent and treat migraines.

In this article, I am referring to Robbins article as I discuss tension headaches and autonomic trigeminal headaches (mainly cluster headaches). See the table below.

Let’s start by looking at the prevention and treatment of tension headaches.

Source: Arash Emamzadeh (adapted from Robbins, 2021)

Tension headache

Tension headaches cause mild to moderate pain: sensations of tightness, dull pressure, or squeezing (as if it were a tight hat). A tension headache attack can last from 30 minutes to seven days. The pain is usually worse in the frontal and temporal areas (i.e. the temples), although it can be severe in other areas as well (for example, the upper neck). Unlike migraines, tension headaches are not significantly exacerbated due to activity; nor are they generally associated with nausea, vomiting, or visual disturbances.

Episodic tension headaches are the most common primary headache (prevalence over one year of about 40%). Chronic tension-type headaches (attacks at least 15 days per month for three months) are less common (2-3%) and often associated with overuse of medications and mental health symptoms (eg, anxiety and depression).

Many tension headache triggers have been reported: psychological stress, fatigue, hunger, loud noises, lack of sleep, eye strain, neck pain (e.g. arthritis, teeth grinding, etc.), consumption of alcohol and drug and mental health symptoms such as anxiety and depression.

The causes of tension headaches may involve both environmental and genetic factors (especially in the case of chronic headaches). In terms of the pathophysiology of episodic tension headaches, widespread theories point to the role of myofascial activity / excitability and pain receptor sensitization. The pathophysiology of chronic headaches can lead to more general changes in the pain circuits of the central nervous system and secondary sensitization.

Treatments for tension headaches include simple pain relievers (eg, acetaminophen, Tylenol brand); nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin (Bayer), ibuprofen (Advil, Motrin), ketorolac (Toradol), diclofenac (Voltaren), naproxen (Aleve) and drug combinations containing caffeine. It is important not to take more medication (or more frequently) than recommended, as this could cause rebound headaches.

Preventive interventions, recommended when seizures are frequent or disabling, include the tricyclic antidepressants amitriptyline (Elavil) and nortriptyline (Pamelor); the tetracyclic antidepressant mirtazapine (Remeron); and the serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor).

Other interventions, such as cognitive behavioral therapy, biofeedback, acupuncture, and trigger point injections, are also recommended.

As with other health concerns, it is essential to consider healthy lifestyle changes: better posture, proper sleeping position, maintaining a regular waking and going to bed, physical exercise, hydration, healthy eating, neck and shoulder stretching, stress management techniques (eg, mindfulness meditation, relaxation, deep breathing, yoga, massage) and modifying environmental factors (eg, noise, heat, ergonomics). Finally, it helps to treat health problems like bruxism (teeth grinding) that make tension headaches worse.

Cluster headaches

Cluster headache is a very painful and rare type of primary headache (prevalence

Cluster headache is characterized by severe pain (often a throbbing, intense, sharp, or burning sensations) on one side of the head, starting from above / behind one eye. This is accompanied by feelings of restlessness and restlessness (eg, rocking back and forth, pacing the room) and autonomic symptoms (eg, same side as the headache. Symptoms of migraine occasional, including sensitivity to light, may also be present.

In 10% of cases, episodic cluster headaches become chronic and last a year or more with pain-free or short-lived periods (eg, 1 to 2 months).

Cluster headaches often occur at night and around the same time. Indeed, the sudden and severe pain woke many patients from sleep. Additionally, attacks tend to occur at the same time of year (eg, usually during seasonal changes, such as early spring).

Some triggers of cluster headache are bright lights, high altitude, increased body heat (eg, hot weather), strong odors, foods containing nitrates, smoking, and using medicines that dilate blood vessels (eg, nitroglycerin, alcohol). Keeping a headache diary can help patients identify the triggers that cause or worsen headaches, so they can avoid them during cluster periods.

Miroslavik / Pixabay

Source: Miroslavik / Pixabay

The cause of cluster headaches is still debated. The pathophysiology of cluster headaches is complex and appears to involve the hypothalamus (the body clock). One view suggests that the pathophysiology of cluster headache involves hypothalamic activation of the trigeminal-autonomic reflex (the cause of autonomic symptoms) and the trigeminovascular system on the same side of the head.

Treatment for cluster headaches consists of non-oral triptans, such as intranasal zolmitriptan (Zomig) or intranasal / subcutaneous sumatriptan (Imitrex), which work by narrowing the blood vessels in the head; inhale pure oxygen (flow rate up to 15 liters per minute); and non-invasive vagus nerve stimulation (for episodic headaches).

Prevention includes the use of calcium channel blockers like verapamil (Calan); lithium carbonate (Lithobid); monthly injections of monoclonal antibodies such as galcanezumab (Emgality); and complementary stimulation of the vagus nerve. Short-term preventative treatments include steroids, such as prednisone (Deltasone) and occipital nerve blocks.

For chronic cluster headaches, stimulation of the sphenopalatine ganglion should be considered.

Other substances, namely melatonin and capsaicin, may also help, although more research in this area is needed. Finally, as with other health concerns, it is important to consider healthy lifestyle changes (eg, stress management, avoidance of alcohol use, and sleep hygiene).


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