eMedicine Specialties > Emergency Medicine > Neurology

Headache, Cluster: Follow-up

Author: Lori K Sargeant, MD, Consulting Staff, Summa Emergency Associates, Inc
Coauthor(s): Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Contributor Information and Disclosures

Updated: Nov 5, 2009

Follow-up

Further Outpatient Care

  • Histamine desensitization
    • Popular in the 1940s and 1950s, histamine desensitization was introduced by Dr Horton at the Mayo Clinic. He treated patients with subcutaneous and intravenous injections. This treatment was based on the contention that metabolic derangement of histamine played an important role in producing cluster headaches.
    • This treatment is used very rarely at the present time.
    • Results were inconsistent. Minimal hard data exist on recurrence rates and follow-up duration.
    • The episodic nature of clusters was not recognized fully at that time. Therefore, spontaneous improvements were attributed to treatment.
  • Surgical
    • Various procedures are performed on trigeminal nerve or autonomic pathways, including alcohol injections and section or avulsion of nerves for chronic refractory cases.
    • Surgery is used if the patient has contraindications to medications or if medications are not effective. Surgery is used in strictly unilateral cases.
    • Radiofrequency thermocoagulation of trigeminal ganglion has had promising results in some patients with intractable pain.

Deterrence/Prevention

  • Patient should avoid headache triggers.
  • Disturbances in the sleep cycle can induce attacks.
  • Strong emotions and excessive physical activity may induce attacks.
  • Tobacco may slow responsiveness to medications.
  • Narcotics may expedite transformation of episodic cluster to chronic cluster.

Complications

  • Self-injury during attack
  • Side effects of medication, including unmasking of coronary artery disease
  • Potential for drug abuse

Prognosis

  • Recurrent attacks
  • Prolonged remissions
  • Possibility of transformation of an episodic cluster to a chronic cluster and vice versa

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Attributing symptoms to cluster headaches when other entities are the cause (eg, subarachnoid hemorrhage)
  • Ignoring psychologic factors (eg, suicidal threats)
  • Not exploring contraindications to medications

Special Concerns

  • Ensure follow-up (medical and psychiatric) if needed.
  • Pregnant and geriatric patients often are not candidates for some pharmacologic interventions.
 


More on Headache, Cluster

Overview: Headache, Cluster
Differential Diagnoses & Workup: Headache, Cluster
Treatment & Medication: Headache, Cluster
Follow-up: Headache, Cluster
References
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References

  1. Tfelt-Hansen P. Acute pharmacotherapy of migraine, tension-type headache, and cluster headache. J Headache Pain. Apr 2007;8(2):127-34. [Medline].

  2. Beck E, Sieber WJ, Trejo R. Management of cluster headache. Am Fam Physician. Feb 15 2005;71(4):717-24. [Medline]. [Full Text].

  3. [Guideline] Biondi D, Mendes P. Treatment of primary headache: cluster headache. In: Standards of care for headache diagnosis and treatment. Chicago (IL): National Headache Foundation. 2004;[Full Text].

  4. [Guideline] Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. Oct 2008;52(4):407-36. [Medline]. [Full Text].

  5. Bahra A, Goadsby PJ. Diagnostic delays and mis-management in cluster headache. Acta Neurol Scand. Mar 2004;109(3):175-9. [Medline].

  6. Diamond ML. Emergency Department Treatment of the Headache Patient. 1992.

  7. Evans RW. Diagnostic testing for the evaluation of headaches. Neurol Clin. Feb 1996;14(1):1-26. [Medline].

  8. Graham JR. Cluster headache. Headache. Jan 1972;11(4):175-85. [Medline].

  9. Henry GL, Rosen P, Barkin R, eds. Headache. In: Emergency Medicine, Concepts and Clinical Practice. 4th ed. 1996:2119-31.

  10. Hoffman GL, Tintinalli JE, Ruiz E, Krome RL, eds. Headache and facial pain. In: Emergency Medicine, A Comprehensive Study Guide. 4th ed. 1996:1009-10.

  11. Manzoni GC, Torelli P. Headache screening and diagnosis. Neurol Sci. Oct 2004;25 Suppl 3:S255-7. [Medline].

  12. Mathew NT. Advances in cluster headache. Neurol Clin. Nov 1990;8(4):867-90. [Medline].

  13. Mathew NT. Cluster headache. Neurology. Mar 1992;42(3 Suppl 2):22-31. [Medline].

  14. Rapoport AM, Bigal ME, Tepper SJ, Sheftell FD. Intranasal medications for the treatment of migraine and cluster headache. CNS Drugs. 2004;18(10):671-85. [Medline].

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Further Reading

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Keywords

cluster headache, cluster headache symptoms, cluster headache causes, histamine headache, cluster headache treatment, histaminic headache, Horton's cephalalgia, Horton's headache, neurovascular headache, episodic cluster headaches, chronic cluster headache, migraine

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Contributor Information and Disclosures

Author

Lori K Sargeant, MD, Consulting Staff, Summa Emergency Associates, Inc
Lori K Sargeant, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Blanda, MD, Chair, Department of Emergency Medicine, Summa Health System; Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
Michelle Blanda, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward A Michelson, MD, Program Director, Associate Professor, Department of Emergency Medicine, University Hospital Health Systems in Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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