inTervieW - Green Cross Publishing

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portions of the cerebral arteries and dura. This
mediates a local inflammatory reaction (plasma
extravasation) which in turn stimulates painful
sensory receptors located on the cerebral
arteries. The sensory afferent painful information
is relayed along the ophthalmic division of the
trigeminal nerve and synapses in the trigeminal
nucleus caudalis in the brainstem (pons). Second
order neurones further relay this information
to the thalamus and third neurones relay the
information to the higher cortical functions in the
brain where pain is perceived.
In addition, at the trigeminal nucleus caudalis
(TnC) in the pons, there is an inter-neuronal
connection between the TnC and superior
salivatory nucleus and this results in activation of
the cranial parasympathetic system which travels
via the greater petrosal, a branch of the 7th
cranial nerve, thus explaining the secreto-motor
symptoms seen in cluster headache (trigeminalautonomic
reflex). The partial Horner’s syndrome
which completes the symptoms and signs is
postulated to be due to sympathetic dysfunction
caused by internal carotid dilatation as it
traverses the cavernous sinus.1
It is prudent that all patients who present with
cluster headaches should be investigated and
have MRI neuroimaging for potential secondary
causes such as an internal carotid artery
aneurysm or lateral protrusion of a pituitary
macroadenoma into the cavernous sinus, both of
which can mimic this disorder.
case sTudy
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TreaTMenT
For over a generation, neurologists have been
using oxygen therapy in the management of the
acute attack. Oxygen therapy has established
itself as a first-line agent and treatment of choice.
The mode of delivery and action is unique to
cluster headache and should be administered as
100 per cent oxygen through a non re-breathing
mask at a high flow rate of 7-10 litres per minute
for 15 minutes.
The efficacy of this treatment has, up to
recently, been anecdotal with up to 70 per cent
of cluster patients getting relief of their headache
and associated symptoms within 10-15 minutes.
A pivotal study by Goadsby et al was published
in JAMA in December 2009 confirming and
validating the use of oxygen therapy.2
The mode of action of oxygen therapy is now
better understood and it is postulated that it
inhibits trigeminovascular and parasympathetic
activation. This inhibition is concentrated at
the superior salivatory nucleus where there is
suppression of parasympathetic nerve fibre
transmission in those fibres travelling via the
greater petrosal nerve.
The only pharmaceutical agent which
has proven efficacy for the acute attack is
subcutaneous sumatriptan 6mg, the triptan
therapy (5-HT-1B/1D receptor agonist). This
parenteral medication is not licensed in Ireland
and is only available on a named patient basis. Its
efficacy is similar to oxygen. nasal sumatriptan
issue 10 volume 12 • novemBeR 2010
has also demonstrated a benefit but has a slower
onset of action. 3
All narcotic agents and other analgesics have
no role in the management of the acute attack.
They have no proven efficacy and this case study
bears testament to this. In addition their habitual
use predisposes the patient to developing
chronic daily headache and medication overuse
headache.
The calcium antagonist, verapramil, is the
treatment of choice as a preventive therapy.
There are many randomised and nonrandomised
clinical trials proving its efficacy. It
can be commenced at a dose of 80mg tds and
titrated upwards if required. Some patients need
to go up to a dose of 480mg. Patients should
be monitored at the higher doses as verapramil
can prolong the PR interval and patients should
have an ECG prior to commencement. Verapramil
blocks the entry of calcium into smooth muscle,
reducing blood vessel dilatation which is
responsible for the severe pain. Patients achieve
a reduction in cluster headache days and the
number of attacks per day.4
references
1. Journal of Headache and Facial Pain. Sept 2009
1131-43.
2. Journal of the American Medical Association.
December 2009.
3. Journal of neurology 2003. 630-33.
4. Headache 2009. 117-25.
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