Posted by Don C. (144.59.63.186) on July 12, 1999 at 00:30:58:
Maybe this will help with those that are having problems with doctors and insurance companies. Here's what my doctor used, even though he was familiar with CH: Griffith's 5 Minute Clinical Consult, printed by Williams and Wilkins 1998, there is also a newer edition supposedly. Can find info on how to get the book at 800-447-8438. I am not advertising the book nor the sale of it. I also am not saying what other doctors have you on or how they are treating you is wrong. The purpose of posting this is to help those who have trouble finding a doctor that is familiar with cluster headaches and giving them a place to go and get smart. Also, maybe it will help with insurance companies on oxygen. If your doctor is treating you, don't go tell him he is wrong because his treatment doesn't agree with what is here. Use this only as a guide to get started. From the book:
Headache, cluster
Basics
Description: Attacks of severe, unilateral headache typically localized in periorbital area and temple associated with ipsilateral lacrimation, rhinorrhea, ptosis, miosis and nasal congestion. Individual attacks last 30-180 minutes and occur 1-6 times per day. Two forms exist: episodic with attack phases lasting 4-12 weeks, followed by a cluster-free interval of generally 6 months to years duration; and chronic, with a cluster-free interval of less than 1 week in a 12 month period of time.
System affected: Nervous
Genetics: Unknown
Incidence/Prevalence in USA: 0.5-1% of adult population
Predominant age: Mean age of onset: 30 years in men, later in women
Predominant sex: Male>Female (6:1)
Signs and Symptoms:
-Sudden onset of severe headache
-Headache reaches cresendo within 15 minutes, lasts <3 hours
-Pain is unilateral, oculo-temporal or oculo-frontal; rare in other locations
-Severe, piercing, boring, exploding, penetrating (occasionally throbing) pain
-Ipsalateral partail Horner's syndrome (ptosis and miosis)
-Lacrimation (84%)
-Injected conjunctiva (58%)
-Ptosis (57%)
-Nasal stuffiness (48%)
-Rhinorrhea (43%)
-Bradycardia (58%)
-Nausea (40%)
-Perspiration (26%)
-Restlessness and agitation during attacks
-Attacks may occur at the same time for consecutive days; frequently an attack occurs within 90 minutes of falling asleep (corresponding to first REM sleep)
Causes:
Unkonown, perhaps:
-Disruption of circadian rhythmn based on hypothalamus
-Disturbed autoregulation of cerebral arteries
-Disorder of serotonin metabolism or transmission in CNS
-Disorder of histamine concentrations or receptors
Risk Factors:
-Male gender
-Age >30 years
-Small amounts of vasodilators, such as alcohol or nitroglycerine
-Occasional relationship to previous head trauma or surgery
Diagnosis
Differential Diagnosis: Diagnosis generally made through carefull history. Differential includes other head and neck pathology, migraine, trigeminal and other facial neuralgias, chronic paroxysmal hermicrania (probably a cluster variant), temporal arteritis, pheochroromocytoma.
Laboratory: Not useful except to rule out differential diagnosis
Imaging: Generally of little value except in atypical presentations or those unresponsive to therapy.
Treatment
Appropriate Health Care: Outpatient except in patient at suicidal risk.
General measure:
-During cluster periods, avoid alcohol, bright lights and glare, excessive emotion and stress as these may precipitate attacks.
-Avoid narcotic analgesics, especially oral preparations.
-Tobacco (high predilevtion for tobacco abuse in this population) may make patients more refractory to therapy.
Surgical Measures: Radiofrequency trigeminal gangliosis in carefully selected refractory patients with strictly unilateral attacks.
Activity:
-Avoid self-injury during bouts of excruciating pain.
-Vigorous physical activity at first symptom may abort attack in some.
-Compression of ipsilateral carotid or temporal artery may reduce pain in some. Caution exercised in recommending carotid massage in patient at risk for occult carotid disease.
Diet:
-During cluster phase, alcohol even in small amounts frequently precipitates attacks.
-Rarely, specific foods may trigger attacks.
Patient Education:
-Focus on the validity, natural history and pathology of the condition.
-Advise patient to avoid known precipitants
-Assist patient with learning self-treatment methods.
-Provide supportive relationship and follow-up.
-Avoid high altitudes.
Medications
Drug(s) of choice:
-General information:
-Prophylactic therapy is paramount
-Avoid pain therapy for acute attacks, especially narcotic analgesics
-Assess cardiovascular risk before instituting vasoactive drugs, such as, ergotamine or sumtriptan
-Acute attcks:
-Oxygen 100% at 7-10 liters for 10-15 minutes administered through a tight fitting face mask with patient in sitting position and breathing at normal respiratory rate.
-Sumatriptan (Imitrex) 6 mg subcutaneous, maximum 12 mg per 24 hours with at least 1 hour between injections
-Dihydroergotamine mesylate (DHE 45) 1 mg IM or IV. May teach self-administration with SC.
-Prophylaxis (to shorten cluster period or prevent expected attcks):
-Verapamil 80 mg PO qid spaced evenly through waking hours.
-Litium carbonate (Eskalith) 300 mg 2-4 times a day.
-Methysergide (Sansert) 4-10 mg daily divided doses tid or qid. More useful in younger patient in early stage of disease.
-Ergotamine timed to ba at peak serum level during anticipated attack, e.g. 2 mg rectal or 1-2 mg oral 2 hours before. This is especially useful to prevent night attacks.
-Prednisone, various schedules, e.g. 60-80 mg PO for 7 days followed by rapid tapering over 6 days or 40 mg/day for 5 days tapered over 3 weeks. This therapy is initiated while other long-term agent is being employed, such as, verapmil or lithium.
My fingers are tired, and won't type rest. (please excuse typos, i'm a two finger typist too) It talks alternative drugs, follow-up and more history, etc of cluster headaches. I hope this is helpful for those of you that are having trouble with doctors diagnosis and maybe insurance companies that won't cover oxygen. Might note, it is the top choice for acute attacks. Again, this information is in no way intended to replace what your doctor is doing or to say that other treatments, causes, etc are wrong. Intent is to give people a start with their own doctor.
Hope it helps, have abeautiful pain free day, Don C./Solo on ICQ