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  Headaches - clusterHighlightsFDA Warning: Serotonin Syndrome In 2006, the FDA issued a warning against using triptan drugs and certain antidepressant medications at the same time. Combining a triptan with a selective serotonin reuptake inhibitor (SSRI) or selective serotonin norepinephrine reuptake inhibitor (SSRI) can result in serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition caused by excess levels of the brain chemical serotonin.
Characteristics of Cluster Headaches Cluster headaches are the most painful of all headaches. According to a 2006 study in the journal Headache, patients with cluster headaches also experience during attacks:
Lifestyle Factors Smoking and alcohol use are associated with cluster headaches. In the Headache study, 66% of patients were current smokers. About half reported that alcohol, usually red wine, was a trigger for the attacks. Management of Cluster Headaches
IntroductionMost people are familiar with headaches, the all too common affliction marked by throbbing, piercing, or vise-like pain around much or a part of the head. There are many different kinds of headaches, and they range from being an infrequent annoyance to a persistent, severe, and disabling medical condition. The brain itself is insensitive to pain, so that is not what hurts when a headache arises. Rather, the pain occurs in the following locations:
Doctors categorize headaches as either primary or secondary, which helps to distinguish the many different kinds of headaches and to determine appropriate treatments for each. Primary HeadachesA headache is considered primary when a disease or other medical condition does not cause it. Most primary headaches fall into three main types: tension-type, migraine, and cluster headaches.
 Headaches are usually caused by muscle tension, vascular problems, or both. Migraines are vascular in origin, and may be preceded by visual disturbances, loss of peripheral vision, and fatigue. Most headaches can be relieved by over-the-counter pain medications. Secondary HeadachesSecondary headaches are caused by other medical conditions, such as sinus infections, neck injuries, and strokes. About 2% of headaches are secondary to abnormalities or infections in the nasal or sinus passages, and they are commonly referred to as sinus headaches. Chronic Daily HeadachesThe International Headache Society has developed a classification system that includes a category called chronic daily headaches. They may originate as tension headaches, migraines, or a combination of these or other headache types. Chronic daily headaches affect 4 - 5% of the population. Chronic daily headaches are defined as any benign headache that occurs at least 15 days a month and is not associated with a serious neurologic abnormality. Most people with these headaches have them daily or almost daily and they can be quite debilitating. Chronic daily headaches are, in turn, subdivided into two categories:
 Click the icon to see an image of the different types of headache. Cluster HeadachesCluster headaches are among the most painful, and least common, of all headaches. The pain can be so excruciating that they are sometimes referred to as “suicide headaches." Their signature is a pattern of periodic cycles (“clusters”) of headache attacks, which may be either:
Symptoms of Cluster HeadachesCluster headaches usually strike suddenly and without warning, although some people experience a migraine-type aura before the attack. A stabbing pain quickly develops behind one eye or on the temple of one side of the head. The pain then spreads to the forehead, jaw, upper teeth, or neck. The pain and other symptoms usually remain on one side of the head. Other typical symptoms include:
 The symptoms of a cluster headache include stabbing severe pain behind or above one eye or in the temple. Tearing of the eye, congestion in the associated nostril, and pupil changes and eyelid drooping may also occur.
CausesCluster headaches, like migraines, are likely due to an interaction of abnormalities in the blood vessels and nerves that affect regions in the face. Abnormalities in the HypothalamusEvidence strongly suggests that abnormalities in the hypothalamus, a complex structure located deep in the brain, may play a major role in cluster headaches. Advanced imaging techniques have shown that a specific area in the hypothalamus is asymmetrical in these patients and is activated during a cluster headache attack. The hypothalamus is involved in the regulation of many important chemicals and nerve pathways, including:  Click the icon to see an image of the hypothalamus.
Circadian Abnormalities. Cluster attacks often occur during specific sleep stages. They also often follow the seasonal increase in warmth and light, beginning in summer and ending in the fall. Researchers have therefore focused attention on circadian rhythms, and in particular small clusters of nerves in the hypothalamus that act like biologic clocks. The most important nervous cluster is the suprachiasmatic nuclei (SCN), which appears to help coordinate the body's activities (sleep/wake) with the environment (dark/light). Some studies support the idea that some failure in this biologic pacemaker may impair the pain control system and cause these terrible attacks. The hormone melatonin is also involved in the body's biologic rhythms. Alterations in Serotonin. The brain chemical serotonin is of particular interest in the study of headaches, particularly migraine and cluster headaches. This neurotransmitter (chemical messenger) affects, among other functions, well-being, sleep, and appetite. Some research has also suggested that serotonin may play an important role in the way circadian rhythms are expressed. There is some evidence of abnormal regulation of brain serotonin levels in patients with cluster headaches (although it is not as pronounced as in patients with migraine). Dilation of Blood VesselsCluster headaches are associated with dilation (widening) of blood vessels and inflammation of nerves behind the eye.  Cluster headaches may be caused by blood vessel dilation in the eye area. Inflammation of nearby nerves may give rise to the distinctive stabbing, throbbing pain usually felt in one eye. The trigeminal nerves branch off the brainstem behind the eyes and send impulses throughout the cranium and face. In both cluster and migraine headaches blood vessels dilate, but in cluster headaches only the blood vessels behind the eyes pulsate. What causes these events and how they relate to cluster headaches are still unclear:
Other FactorsNitric Oxide. Nitric oxide is a small molecular messenger that activates nerve pathways in the brain, muscles, or elsewhere. It may contribute to major primary headaches (tension-type, cluster, and migraines) by specifically triggering inflammation and overactivity in the trigeminal nerves. (This is a major nerve pathway that runs from the brain stem to the head and face.) However, other factors must be present that make patients with cluster headaches susceptible to the actions of nitric oxide. Immune Abnormalities. Researchers are also investigating whether overproduction of certain immune factors called cytokines may contribute to cluster headaches. Cytokines, such as interleukins, are known to cause inflammation and injury in high amounts. To date, however, there is no evidence that they play any role. Abnormalities in the Sympathetic Nervous System. Some evidence suggests that abnormalities in the sympathetic (also called autonomic) nervous system may contribute to cluster headaches. This system regulates non-voluntary muscle actions in the body, such as in the heart and blood vessels.
 Click the icon to see a depiction of glaucoma.  Click the icon to see an image of the slitlamp test.  Click the icon to see an image of the visual field test.
PrognosisThe pain of cluster headaches can be intolerable. In fact, a higher-than-average rate of suicide has been reported in men with these headaches. Eventually, the attacks cease, but experts cannot predict when or how they will end. Effects on Mental and Emotional FunctioningPeople with episodic cluster headaches tend to have low sexual appetites and impaired verbal memory and are more likely to suffer from anxiety. According to one study, nearly a quarter of patients with cluster headaches met the criteria for having anxiety disorders. Furthermore, the anxiety disorders occurred more frequently within the year before the onset of their cluster headaches. (None of these patients had depression or abused alcohol or drugs.) Some studies suggest that the biologic abnormalities in the hypothalamus of the brain that are associated with episodic cluster headaches may also contribute to these emotional and mental difficulties. A 2000 study suggested that the use of antidepressants that regulate serotonin and sleep may reverse mental impairment as well as improve well-being. Auras and Stroke RiskIn rare cases, patients with cluster headaches experience migraine-like aura. Headaches that are accompanied by aura may increase the risk of stroke or transient ischemic attack (TIA). A 2005 study found that patients who had headaches with auras were about four times more likely to have a stroke or TIA than patients who had headaches without aura. TIA symptoms are similar to those of stroke, but last only briefly. A TIA is often a warning sign that a person is at risk for a more severe stroke.
Risk FactorsCluster headaches are rare, affecting less than 1% of the population. Cluster Headaches in Men. Cluster headaches are much more common in men than in women, about 85% of cluster headache sufferers are men. The peak age of onset for men is the 20s to early 30s. Cluster Headaches in Women. Studies of cluster headaches in women report that there are two ages of peak onset, the 20s and 50s. In some studies, attacks in women were of shorter duration than in men, but the duration of the episodes and length of remission were similar. Unlike with migraines, fluctuations in estrogen and other female hormones do not appear to influence the onset of attacks, although attacks may be less frequent during pregnancy. AgeCluster headaches typically start in the late twenties. In rare cases they begin in childhood, and about 10% of cases develop after age 60. Lifestyle FactorsLifestyle factors, including smoking, alcohol abuse, and stress (in particular stressful work situations), appear to play a very strong role in cluster headaches. Smoking or alcohol use can trigger attacks. In a 2006 study, 70% of people with cluster headaches were current smokers. About half reported that alcohol (most commonly red wine) triggered an attack. Family History and Genetic FactorsEvidence for genetic factors has been weak, but there is a growing body of research suggesting a family history in about 5 - 10% of patients. Some evidence suggests that cluster headaches in women may be more likely to be genetically based, particularly when they first occur at younger ages. History of MigraineA 2002 study reported that 26% of cluster headache sufferers also had a personal history of migraines, and 33% had a family history of this headache. Studies have reported that about 15% of patients have both kinds. Head InjuryHead injury may also increase the risk of cluster headaches. In one study, over 13% of patients reported a history of a head injury that caused loss of consciousness, and nearly a quarter had experienced a head injury without loss of consciousness. Sleep Apnea and Other Sleep DisordersCluster headaches tend to occur during specific sleep stages and have been associated with several sleep disorders, including narcolepsy, insomnia, and sleep apnea. Sleep apnea, a disorder in which a person stops breathing during the night, perhaps hundreds of times, is of particular interest. Studies have reported sleep apnea in 30 - 80% of patients with cluster headaches. One study suggested that in some people apneas may trigger cluster headache during the first few hours of sleep, making patients susceptible to follow-up attacks during the following midday to afternoon periods. Treating patients who have both disorders with a device called CPAP, which opens the airways, may help improve both conditions. [For more information, see In-Depth Report #65: Sleep apnea.]
DiagnosisIn two surveys, patients reported a delay of 1 - 6 years in the diagnosis of their headaches. In one of the surveys, migraine-like symptoms (light and sound sensitivity and nausea) were major reasons for the frequent misdiagnosis by family doctors. About a third of the patients sought help from dentists and another third from ear-nose-throat specialists. In most cases, patients were inappropriately treated for other types of headaches (including having sinus surgery). Medical and Personal HistoryFor an accurate diagnosis, the patient should describe:
Headache Diary to Identify TriggersThe patient should try to recall what seems to bring on the headache and anything that relieves it. Keeping a headache diary is a useful way to identify triggers that bring on headaches:
Physical ExaminationIn order to diagnose a chronic headache, the doctor will examine the head and neck and will usually perform a neurologic examination, which includes a series of simple exercises to test strength, reflexes, coordination, and sensation. The doctor will also examine the eyes to rule out pressure build-up in the eye as a cause of headache. The doctor may ask questions to test short-term memory and related aspects of mental function. Ruling Out Other Headaches and Medical DisordersAs part of the diagnosis, a doctor should rule out other headaches and disorders. If the results of the history and physical examination suggest other or accompanying causes of headaches or serious complications, extensive imaging tests are performed. Migraines. Cluster headaches are often misdiagnosed as migraines but they are quite different:
Nevertheless, in both cases, the headache suffers can be highly sensitive to light and noise, which may make it difficult to distinguish between them. Other Headaches. Other headaches that resemble migraines include SUNCT and chronic paroxysmal hemicrania, which are other primary headaches, and some secondary headaches notably trigeminal neuralgia (TN), temporal arteritis, and sinus headaches. Cluster symptoms, however, are usually precise enough to rule out these other types of headaches. Tear in the Carotid Artery. A tear in the carotid artery (which leads to the brain) can cause pain that resembles a cluster headache. People with this condition may even respond to sumatriptan, a drug used to treat a cluster attack. Doctors should consider imaging tests for patients with a first episode of cluster headache in which this event is suspected. Orbital Myositis. An unusual condition called orbital myositis, which produces swelling of the muscles around the eye, may mimic symptoms of cluster headache. This condition should be considered in patients who have unusual symptoms such as protrusion of the eyeball, painful eye movements, or pain that does not dissipate within three hours. Imaging TestsImaging tests of the brain may be recommended under the following circumstances:
Imaging tests are not recommended for patients with migraines and no other abnormal indications. The following tests may be used:
Managing Cluster HeadachesPatients with cluster headaches face significant difficulties in the management and treatment of their problems:
Treating AttacksThe most effective treatments for a cluster attack are:
Relief can occur in 5 - 10 minutes. Preventing AttacksBecause effective therapy for cluster headaches is limited, most research efforts focus on the prevention of attacks during cluster cycles. A number of treatments are available and may be used alone or in combination. In general, the steps for preventive management are: Transitional Medications. Patients should use headache medications (typically a triptan, a corticosteroid, or ergotamine) to control any attacks during the transition to on-going maintenance drugs. Maintenance Drugs. Prevention of attacks during a cluster cycle is extremely important. Although patients with episodic or chronic cluster headaches may be given different medications, there does not appear to be much difference in their effectiveness for either type. The following are the most commonly used preventive drugs:
Other drugs that have been tried include indomethacin, melatonin, beta blockers, tricyclic and other antidepressants, and capsaicin. Combinations may be needed. Behavioral TreatmentsLifestyle Changes. Patients should avoid the following:
One study suggested that vigorous physical exertion at the sign of an attack onset may help reduce or even abort an attack. SurgerySurgery may be considered for patients with chronic cluster headaches that do not respond to medications. However, surgery is also limited in its effectiveness. Treatment for Sleep ApneaPatients with cluster headaches who suffer from daytime sleepiness should consider being evaluated for a possible diagnosis of sleep apnea. Anyone who has both conditions should strongly consider treatment for the apnea as possible therapy for cluster headaches. Continuous positive airway pressure (CPAP) is the standard treatment for sleep apnea. In some studies, patients with both cluster headaches and apnea who were treated with CPAP experienced substantial reduction in the frequency and severity of cluster headaches. [For more information on CPAP and sleep apnea, see In-Depth Report #65: Sleep apnea.] Treatment for Acute AttacksOxygen TherapyBreathing pure oxygen (by face mask, for 15 minutes or less) is one of the most effective and safest treatments for cluster headache attacks. It is often the first choice. Inhalation of oxygen raises blood oxygen levels and therefore relaxes constricted blood vessels. TriptansTriptans are drugs that are usually used to treat migraine headaches. They can also help stop a cluster attack. Injections of sumatriptan (Imitrex) are the standard triptan treatment. Sumatriptan injections work within 15 minutes in about three quarters of cluster attacks. The nasal spray form is also effective, and generally provides relief within 30 minutes. The spray seems to work best for attacks that last at least 45 minutes, although some people find it does not work as well as the injectable form. Newer triptans used for cluster headache treatment include rizatriptan (Maxalt), naratriptan (Naramig, Amerge), and zolmitriptan (Zomig). A 2006 study of zolmitriptan nasal spray indicated it was effective for cluster headache relief with few side effects. Side Effects. Many of the newer triptans may have fewer severe side effects than sumatriptan. Side effects of most triptans, however, may include:
Complications of Triptans. The following are potentially serious problems with triptans.
The following groups should avoid triptans or take them with caution and only under doctor supervision:
ErgotamineInjections of the ergotamine-derived drug known as dihydroergotamine (DHE) can stop cluster attacks within 5 minutes in many patients, offering benefits similar to injectable sumatriptan. Ergotamine aerosols or ergotamine suppositories with caffeine may also be useful. When using the aerosol the patient usually inhales two or three times. They should be sure to shake the canister vigorously and administer the spray while making an inhalation immediately after a forced exhalation. The patient should then hold the breath for several seconds before slowly exhaling. Proper administration can produce an effective response 80% of the time. (Oral and under-the-tongue preparations of ergotamine are ineffective because of the brevity of cluster attacks.) Local AnestheticsLidocaine, a local anesthetic, may be useful in nasal-spray or nasal-drop form for aborting cluster attacks. Some reports suggest that it is helpful for most patients within about 40 minutes. Preventive MedicationsCalcium-Channel BlockersCalcium-channel blockers, commonly used to treat heart disease, are important drugs for preventing cluster headaches. Verapamil (Calan) is the standard calcium-channel blocker used for headache prevention. Constipation is a common side effect. No one taking any calcium-channel blocker should withdraw the drug abruptly, because this can dangerously increase blood pressure. Overdose can cause dangerously low blood pressure and slow heart beats. Drinking grapefruit juice or eating grapefruit with these drugs can enhance their potency, sometimes to toxic levels that can cause heart failure in patients with heart disease. LithiumLithium (Eskalith, Lithane, Lithobid, Lethonate, Lithotabs), commonly used for bipolar disorder, can also help prevent cluster headaches. The patient usually experiences benefits within 2 weeks, and often within the first week. Lithium may be used alone or with other drugs. Side Effects. Side effects include:
More severe reactions, which occur at higher blood levels, are:
Very high blood levels of lithium can be fatal. If toxicity occurs, drugs should be stopped immediately and one or more of the following steps taken, depending on severity:
Long-Term Side Effects. Even for patients who do not experience a toxic response, long-term use of lithium is not without problems. Some patients may experience:
Drug Interactions. Because lithium is eliminated from the body by the kidneys, any drugs or dietary factors that slow the kidneys' actions may increase lithium blood levels and should be used with great caution. Such drugs include:
There have been reports of interactions between lithium and certain drugs commonly used in combination, including:
Other Factors That Affect Lithium Levels. In addition to drugs, other factors may affect lithium levels, including:
Patients should be sure to contact their doctor if they have any suspicious symptoms or illnesses. Valproate and Other Anti-Seizure DrugsValproate. The anti-epileptic drug valproate (valproic acid, divalproex sodium, Depakene, Depakote) has been used with some success for preventing cluster headaches. It controls pain and reduces the frequency of attacks by more than half in many people with episodic or chronic cluster headaches. Side effects include nausea, vomiting, heartburn, increased appetite with weight gain, hand tremors, irritability, and temporary hair thinning and loss (taking zinc and selenium supplements may help reduce this effect). It can also cause birth defects and, in rare cases, liver toxicity. Topiramate. Other, newer anti-seizure drugs that have fewer side effects are being investigated for chronic headaches. Studies on topiramate (Topamax) are promising. In small trials of topiramate, up to 87% of patients achieved remission, and 60% achieved a complete response. Still, about 25% of patients stop using it, either because it doesn't work or because the side effects are intolerable. They can include drowsiness, mood changes, tremor, and confusion. Gabapentin. Another anti-seizure drug that has shown some benefit in isolated cases is gabapentin (Neurontin). Research on this drug in patients with cluster headaches, however, remains very limited. Side Effects of Valproate and Other Anti-Seizure Drugs. The side effects given here are mostly associated with valproate. Other anti-seizure drugs have similar effects and some specific ones of their own. Most are usually minor, occurring early in therapy, and then subsiding. Those of valproate include:
Very serious side effects are rare but include the following:
CapsaicinA nasal spray form of capsaicin called civamide (Zucapsaicin) has shown promise in the prevention and treatment of cluster headaches. Capsaicin is a component of hot red peppers that seems to reduce substance P, a chemical in the body that contributes to inflammation and the delivery of pain impulses. In a small 2002 study, daily use of intranasal civamide resulted in more than a 50% reduction in headaches. Side effects include a burning sensation and excessive tearing. Transitional DrugsCertain medications are useful as transitional drugs. These medications are used after cluster episodes to stabilize the patient until preventive maintenance becomes effective. Methysergide. Methysergide (Sansert) is also used for preventing episodic cluster headaches. (It is not very effective for chronic cluster headaches.) Improvement usually occurs within a few days, although it may be delayed for up to 2 weeks. Prolonged methysergide therapy can cause serious side effects, including scarring of internal organs, so it cannot be used long term. This is not usually a problem for patients with cluster headaches, since they only require the drug for about 4 - 6 weeks. Nevertheless, patients should immediately report to their doctors any of the following symptoms: cold, numb, and painful hands and feet; leg cramps on walking; any type of back or chest pain. Ergotamine. Drugs containing ergotamine (sometimes called ergots) cause contractions of smooth muscles, including those in blood vessels, and are commonly used for migraine. Taking them before an expected cluster attack produces good results for many patients. One ergot-derived drug called dihydroergotamine (DHE) is administered by injection, which can be performed by the patient at home. It is also available as a nasal spray (Migranal), which may have fewer side effects than the injection. Ergotamine itself is available in oral tablets (Ergomar, Wigraine, Ercaf) and in rectal suppositories (Cafergot). Cafergot, Wigraine, and Ercaf contain caffeine. An ergotamine inhaler is being investigated. Side effects of ergotamine include nausea, dizziness, tingling sensations, muscle cramps, and chest or abdominal pain. Ergotamine has toxic effects at high levels. It also causes persistent blood vessel contractions, which may pose a danger for people with heart disease or risk factors for heart attack or stroke. Pregnant women, people over age 60, and those with serious, chronic health problems, particularly those of the heart and circulation, should avoid these medications altogether. As with other migraine drugs, if ergotamine is taken more than twice a week, the patient is at risk for rebound headaches when the drug is withdrawn, although cluster headaches appear to be at lower risk for this effect than other types of headaches. Corticosteroids. A corticosteroid is very useful as a transitional drug for stabilizing patients after an attack until a maintenance drug, such as a calcium-channel blocker, begins to take effect. The corticosteroid drug prednisone is effective in up to 90% of patients with episodic cluster headaches. The drug is typically taken for a week and then gradually tapered off. If headaches return, then it may be administered again. Unfortunately, long-term use of steroids can lead to serious side effects so they cannot be taken for on-going prevention. Other Drugs Investigated for PreventionBaclofen (Lioresal). Baclofen is a drug that relaxes muscle spasms. Small studies have reported some success. For example, in a 2001 study, 12 of 16 patients reported an end of attacks within a week and another one became headache-free by the second week. (The remaining three patients became worse, however, and required other drugs.) Three of the patients who improved experienced an additional cluster cycle, which cleared when they took another course of baclofen. Botulinum. Botulinum toxin A (Botox) injections are being used for several conditions requiring muscle relaxation, including smoothing wrinkles. (This potentially deadly toxin is very safe when minuscule amounts are injected into small muscles.) Botox has shown promise for migraine and tension headache sufferers and is now being studied for cluster headaches as well. It is too early yet to gauge any real benefits. Alternative TherapiesMelatonin. Small reports indicate that melatonin, a brain hormone that helps to regulate the sleep-wake cycle, may help prevent episodic or chronic cluster headaches. Melatonin supplements are sold in health food stories, but as with most natural remedies, the quality of different preparations varies, and they have not been rigorously tested for safety or effectiveness. Hormones such as melatonin are powerful substances, and additional studies are needed. Glucosamine. There have been some reports that glucosamine, an alternative remedy commonly used for osteoarthritis, may prevent migraine attacks. Some researchers theorize this substance may reduce inflammation that affects nerves involved in vascular headaches. Whether it has any effect on cluster headaches is unknown. Additional Therapies. Many patients with cluster headaches try alternative remedies for relief of pain. Treatments may include acupuncture, herbs, chiropractic, homeopathic remedies, reflexology, hypnosis, spiritual therapies, massage, aromatherapy, relaxation techniques, and yoga. A 2002 survey of patients attending a headache clinic or support groups, however, did not find any of these alternative therapies to be consistently effective. SurgerySurgical intervention may be considered for patients with chronic cluster headaches that do not respond to treatments. Patients whose headaches have not gone into remission for at least a year may also be candidates for surgery. Most surgical approaches for cluster headache are still considered experimental. To date, surgery has shown limited success and can have distressing side effects. However, some surgical techniques, such as deep brain electrical stimulation, are showing promise. Deep Brain Electrical StimulationRelief of chronic cluster headaches has been achieved in a small number of patients using deep brain stimulation (also called neurostimulation). A similar technique is approved for treating the tremors associated with Parkinson’s disease. The surgeon implants a tiny wire in a specific part of the hypothalamus, which receives electrical pulses from a small generator implanted under the collarbone. Although only a handful of patients have been treated, results to date are promising. Some patients have remained completely free of pain for an average of more than seven months when the electrode is switched on. When the device is turned off, headaches reappear within days to weeks. The procedure is reversible and appears to be generally safe, although one patient developed a fatal cerebral hemorrhage within 4 hours of the procedure. Vagus Nerve StimulationThe vagus nerve runs between the brain and the abdomen. Vagus nerve stimulation (VNS) is a surgical procedure in which a small generator is placed under the skin on the left side of the chest. A surgeon makes a second incision in the neck and connects a wire from the generator to the vagus nerve. A doctor programs the generator to send mild electrical pulses at regular intervals. These pulses stimulate the vagus nerve. VNS is sometimes used to treat epilepsy and depression that does not respond to drugs. It is also being investigated as a possible treatment for chronic migraine and cluster headaches. In a 2005 study of six patients, VNS improved headache and helped a few patients return to work. Procedures to Block or Remove Facial Nerves That Cause PainPercutaneous Radiofrequency Retrogasserian Rhizotomy. Percutaneous radiofrequency retrogasserian rhizotomy (PRFR) generates heat to destroy pain-carrying nerve fibers in the face. Small studies have reported good to excellence results in 83 - 92% patients. Unfortunately complications are common and include numbness, weakness during chewing, changes in tearing and salivation, and facial pain. In severe, but rare, cases, complications include damage to the cornea and vision loss. Percutaneous Retrogasserian Glycerol Rhizolysis. Percutaneous retrogasserian glycerol rhizolysis (PRGR) is a less invasive technique than PRFR and has fewer complications. It involves injections of glycerol to block the facial nerves that cause the pain. In one study, 83% of patients reported immediate relief after one or two injections. Cluster headaches recurred, however, in about 40% of the patients. Microvascular Decompression of the Trigeminal Nerve. Microvascular decompression frees the trigeminal nerve from any blood vessels that are pressing against it. In one study, over 73% of patients reported at least 50% relief. Half of these patients reported 90% relief, but the level of benefit fell to less than 50% over time. Repeat procedures are rarely successful. The procedure is risky, and possible complications include nerve and blood vessel injury and spinal fluid leakage. It does not, however, have the common nerve damage effects in the face that PRFR does. Resources
ReferencesCittadini E, May A, Straube A, Evers S, Bussone G, Goadsby PJ. Effectiveness of intranasal zolmitriptan in acute cluster headache: a randomized, placebo-controlled, double-blind crossover study. Arch Neurol. November 2006. [Epub ahead of print 11 September 2006] Schurks M, Kurth T, de Jesus J, Jonjic M, Rosskopf D, Diener HC. Cluster headache: clinical presentation, lifestyle features, and medical treatment. Headache. 2006 Sep;46(8):1246-54. Van Vliet JA, Eekers PJ, Haan J, Ferrari MD; Dutch RUSSH Study Group. Evaluating the IHS criteria for cluster headache -- a comparison between patients meeting all criteria and patients failing one criterion. Cephalalgia. 2006 Mar;26(3):241-5.
Review Date:
10/19/2006 Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-
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