Cluster Headache (Migrainous Neuralgia)

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Migrainous neuralgia is a severe cephalea (headache), localized unilaterally, which usually occurs in bursts over a period of several weeks to several months. While common cephalea can create a certain discomfort, this type of cephalea is debilitating. It was also called “suicidal cephalea” just because of the unbearable pain. Although the pain can be temporarily unconfirmed, it does not cause permanent damage.
It is relatively rare, more common in men than in women.


The cause of migraine neuralgia is not known. It seems to have a genetic component, because children of parents who suffer from this disease are more likely to develop it.
Migrainous neuralgia seems to be caused by a dysfunction of the hypothalamus (the area of the brain) although a specific problem or an anomaly at this level, which should react to certain triggers, was not clearly identified.
Alcohol consumption, sleep apnea (stopping breathing during sleep), stress, fatigue or some vasodilator drugs (which dilate blood vessels), such as nitroglycerin, can be considered triggers of this disease or they can worsen the evolution of the cycle once started.


The symptoms of migrainous neuralgia are:
- Headaches that occur suddenly, without warning (without the so-called prodrome, the totality of the sensations that signal the beginning of the crisis);
- The pain is severe, fierce, piercing, like a sunburn;
- It affects only one side of the face, neck or head;
- Drooping eyelid;
- Red, weeping eyes with a contracted pupil on the affected side;
- Nasal obstruction and rhinorrhea (stuffed nose and “runny nose”) at the level of the nostril that belongs to the affected hemicranium;
- Pain usually appears after 2 to 3 hours of sleep;
- The pain quickly intensifies, reaching a peak intensity at 5 to 10 minutes after the onset;
- The intense pain can last from several minutes to 3 hours;
- The appearance of sweat on the forehead;
- The appearance and sensation of heat and rash (redness) on the face or forehead of the affected side.
Usually, the onset of a new burst occurs at a free interval after the first episode, lasting between a few minutes and several hours. There may be cycles of 1 to 8 bursts of a headache during a day. In the free interval between the episodes, the patient presents himself exhausted both physically and mentally. When the cycle has stopped, the period of remission until the next burst, may be of days, weeks or even years.
Most people believe that the appearance of a severe headache is related to the existence of a brain tumor or other serious diseases. However, the existence of these episodes of severe cephalea is not associated with a serious health problem. Generally, headaches are caused by common problems such as arterial hypertension, hordeolum (a disorder of the eyelid, commonly called “stye”), dental problems or sinusitis. Very few of the headaches are caused by serious medical diseases.
Other diseases (such as migraine or trigeminal neuralgia) can give similar symptoms with those of the repetitive headache. Usually, the differential diagnosis is made by the doctor after a thorough medical history and a serious clinical examination.

Physiopathogenic mechanism

Most individuals with migrainous neuralgia have 1 or 2 painful cycles a year, each lasting from 1 to 3 months. After the cycle ended, it follows a period of remission from 6 months to 2 years.
It may begin while sleeping, usually after 2 or 3 hours of sleep. It can occur both while the individual is dreaming, as well as throughout the day, manifesting itself in bursts of 1 to 8 episodes per day.
Cephalea is located unilaterally at the level of the head. The pain is penetrating, like a knife shot, usually in and around the affected eye. It can extend up to the temple, forehead, cheeks, upper jaw or the mandible on the affected side. It may sometimes be associated with nasal obstruction, rhinorrhea, watery eyes and drooping eyelids unilaterally.
The pain intensifies quickly – usually in 5 to 10 minutes after the onset – and remains constant over a period of 30 to 45 minutes, sometimes up to a maximum of 3 hours. It may continue for days, weeks and even months until the symptoms reduce completely. Another cycle appears after a free interval of several months to several years. In exceptional cases, pain can become chronic.During such a cycle, the individual may be restless, agitated and unable to stay in one place. Some patients relieve their pain by various methods, such as kneeling, sitting, standing or running. Applying a constant pressure at the level of the painful hemicranium may produce a certain relief. On the contrary, when lying down pain intensity increases. At the end of the painful episode, the individual is physically and mentally exhausted. Another burst may come soon. In time, migrainous neuralgia may evolve to worsening, the painful episodes becoming longer and the period of remission shorter. There are people who may have a single episode of cephalea. A cycle has on average up to 8 painful bursts a day for a period of 6 to 12 weeks, being followed by a free interval that can take weeks, months or even years.

Risk Factors

The risk factors for migrainous neuralgia are:
- Family history. The possibility of the appearance of this type of cephalea increases for those who had parents or relatives with this disease;
- Males. Increased incidence in men than women;
- Age between 30 and 40 years, although it can occur at any age. But it is extremely rare in children under 10 years.
The triggers of the headache with bursts are:
- Smoking. Most individuals with headache with bursts were or are smokers
- Consumption of alcohol. Alcohol is a trigger for headaches, especially during a cycle
- Administration of medications containing nitroglycerin or histamine during the cycle
- Eating certain foods, like cheese or processed meat (hot dogs).
Consulting a specialist
Emergency services wil be immediately called if:
- There is a sudden, severe headache, different from other types of pain from the past;
- It is accompanied by stiff neck, fever, nausea, vomiting, lethargy, drowsiness and confusion;
- Muscle weakness, paralysis, numbness, blurred vision, difficulty when speaking, confusion or behavioral changes appear;
- The intense pain caused by this condition can lead to suicidal thoughts.
Consult your doctor immediately if:
- Severe headache with a sudden onset in the absence of antecedents;
- It comes after a recent head injury;
- The headache is installed gradually and accompanied by confusion, lethargy, impaired gait or loss of sphincter control (involuntary loss of urine or feces).
It is recommended to consult a GP if:
- The patient is woken up repeatedly by severe headaches, with their appearance especially at night or early in the morning
- The first episode of severe headache is around the age of 50 years
- The change of the pattern of headaches takes place
- Headache occurs after exercise, sexual intercourse, coughing or sneezing
- Medications do not relieve pain
- Headaches interfere with normal daily activities
- It is accompanied by depression or anxiety
- Daily burst headaches occur and do not remit after taking common painkillers
- In children, there are headaches with daily occurrence which worsens over time.
Not all frequent headaches are classified in the condition called migrainous neuralgia.

Watchful Waiting

Migrainous neuralgia must be treated with medication prescribed by a doctor, so that watchful waiting is not necessary in this case. If the patient has symptoms typical of this condition, he should consult a doctor.

Recommended medical specialists

Neuralgia, migraine is a condition that can be treated, medication reducing the frequency and severity of crises. The following doctors can diagnose and treat this condition:
- Family doctors
- General practitioners
- Doctors of internal medicine
- Neurologists.


Your doctor can usually diagnose repetitive headache on the basis of an anamnesis (medical history) and a thorough clinical examination. Since this condition presents a classic set of symptoms, the positive diagnosis is made in most cases on the basis of the description of headache crises.
If painful episodes are not alleviated by treatment, becoming chronic or the onset occurs after the age of 50, the doctor may recommend a series of imaging tests in order to eliminate other possible causes of headaches. Imaging tests may also be recommended if there are changes in the pattern of symptoms or howls of pain, if there are serious medical conditions like cancer or diabetes or if the headache is triggered by physical exercises, sexual intercourse, coughing or sneezing.
The most used imaging tests in order to assess headaches are:
- Magnetic resonance imaging (MRI). It can detect the abnormal changes in the brain substance. It is usually used to rule out other problems, such as brain tumors, thrombosis (blood clots in blood vessels) or aneurysms (bulging the portions of a blood vessel). But most headaches are not caused by severe illnesses.
- Computed tomography (CT). This produces a detailed picture of the structures inside the body. It can detect severe and unusual medical conditions, such as brain tumors.
These tests are performed at the doctor’s recommendation, which may indicate further testing such as blood tests or urine tests when there are doubts about the diagnosis.

Initial treatment

The most effective treatment for headache with bursts is the one with drugs. There are two classes of drugs used in treating the disease, namely: the prophylactic ones used to prevent or reduce the number of painful cycles and the healing ones, which reduce the severity of painful crises and of the accompanying symptoms of the cycle. 
Curative medication is the most common and includes:
- Sumatriptan, administered by injection – produces the narrowing of blood vessels (vasoconstriction), thereby reducing pressure and pain. This drug can be administered also in the form of nasal sprays, but it is less efficient than its administration by injections
- Ergotamine preparations, as well as Caffeine Ergotamine, with a vasoconstrictor effect and reducing the pressure and the headache
- Lidocaine administered intranasally in the form of drops – reduces or stops the severe headaches.
Another treatment that stops the pain in about 10 to 20 minutes after the onset is:
- Oxygen therapy – The oxygen is administered by mask and it is responsible for the decrease of blood flow to the brain, thus relieving pain. The treatment should be repeated at every burst of the headache during a cycle.
The most commonly used prophylactic medication includes:
- Calcium channel blockers – such as Verapamil, relax and dilate the narrowed blood vessels, thereby reducing pain. Verapamil is the first drug choice and it is used to prevent occasional or chronic headache bursts;
- Corticosteroids – such as Prednisone, may interrupt the evolution of a cycle, although the mechanism of action of this drug is not fully understood;
- Anticonvulsant drugs – such as Divalproex sodium, Valproate sodium or Topiramate can be used if other medications have not given the desired result;
- Lithium – Lithium carbonate is a drug that acts on the hypothalamus (the brain’s biological clock), considered by some experts as being responsible for the occurrence of cluster headache, although no specific abnormalities were identified at this characteristic level of the disease in cause. Lithium is used usually to prevent the occurrence of headache in chronic bursts.
 Methysergide (ergotamine derivative) was prescribed for a period for the treatment of headaches, but it is no longer available in pharmacies in some countries. The identification and avoidance of headache triggers helps to prevent and reduce the number of bursts during cycle. Avoiding alcohol, tobacco and certain foods (cheese and processed meat) reduces the number of headache episodes per cycle.
A personal diary focused on describing the crises can help your doctor identify the triggers and develop the most effective treatment.
If headaches are not relieved by medication or their pattern changes, the doctor may recommend a series of imaging tests to rule out other possible causes.
The chronic, severe and debilitating headache, characteristic of this disease, can cause depression and even suicidal thoughts. Therefore, repetitive headache is also called “suicidal headache”. It is important for the doctor to know the severity of pain, because it allows him to identify the most effective treatment for the patient in question.

Treatment if the disease gets worse

Usually, changing medications leads to the amelioration of symptoms. Sometimes the prophylactic medication is more necessary in order to prevent the occurrence of headaches, than the curative one that stops headaches as they occur. If the headache worsens, changes its pattern or becomes chronic it is necessary to consult a specialist. The patient can help the doctor identify the pattern of the occurrence of headaches by writing a diary.
If pain is severe and frequent one may resort to oxygen therapy at the doctor’s recommendation. The administration of oxygen 100% by mask, soon after the onset of the burst reduces or even stopspain in 10 to 20 minutes. This treatment is effective in most patients, but there are individuals who do not respond to it.
If headache pattern changes, headaches becoming more severe or are not relieved by medication, your doctor may recommend a series of imaging tests in order to rule out other possible causes.

Other treatments

In rare cases, when the headache does not respond to usual treatments, you can also resort to histamine intravenous desensitization. During this treatment, hospitalization is required. The technique consists of intravenous administration of large amounts of histamine. Although histamine reduce the frequency and severity of burst headaches, its way of action is unclear.
Surgery and radiation therapy treatments can be considered backup treatments of headache with bursts. Since both can produce destructive and permanent changes in the brain, they are rarely used. Their effectiveness is still under study.
The surgical treatment through which the trigeminal nerve is split (the nerve that controls the sensitivity of the face) is used only at individuals presenting burst headaches always on the same side of the head.
Radiation therapy, which focuses a beam of radiation on the trigeminal nerve, may decrease facial sensitivity and reduce the pain from the burst headaches.
To be retained!
To find the optimal treatment the doctor must think of several drug combinations. If burst headaches are inconsistent, then the medication will be administered only during the time they occur. If, on the contrary, burst headaches occur frequently and regularly, it will be necessary to administer a medication which must prevent and reduce the number of painful cycles.


For the time being, there is no method to prevent the onset of burst headache because its cause is not known yet. However, once diagnosed, it is important to identify and avoid the triggers in order to reduce the severity and duration of headaches.
The most involved common triggers are:
- Alcoholic drinks;
- Smoking;
- Changes in the hours of sleep pattern; for example, sleeping in the afternoon seems to cause burst headaches;
- Stress; some individuals complain about the appearance of burst headaches after a stressful event. Reducing stress through activities such as regular exercise, prevents headaches.

Treatment at home

The pain of burst headaches can be debilitating. The identification and avoidance of triggers (such as alcohol and tobacco) may reduce the severity and the duration of cycles.
The headache management at home includes:
- the use of oxygen therapy by mask can reduce pain in 10 to 20 minutes;
- Adequate drug dose soon after the onset of the burst headache;
- Keeping a diary in which the details of the appearance of burst headaches, the frequency, the severity of symptoms and the triggers suspected for the onset will be noted. This diary must be taken at each visit to the doctor because it may provide useful information for establishing an effective treatment.
An effective home management leads to the decrease of severity and duration of the headache cycles.
If headaches become more severe and the medication is ineffective, your doctor must be informed about it. Changing medications or a drug combination may be necessary in this case.
Chronic burst headaches lead to stress and depression, both causing the worsening of the painful cycles. Finding ways to reduce stress (such as regular exercise) can reduce depression, severity and frequency of burst headaches.


Medicines can stop this kind of headache and may prevent the occurence of additional headaches. Finding an effective individualized treatment needs time. Drug combinations can also be recommended for an effective treatment. The medications used to treat burst headaches are called curative and the drugs used to prevent headaches are called prophylactic. Both types were presented in the points mentioned above.
To be retained
Usual analgesics (such as aspirin, acetaminophen (Tylenol) or ibuprofen) do not usually lead to the reduction of repetitive headache pain, for this being necessary specific drugs.
The administration of the prescribed medication as soon as possible after the start of a burst of headache leads to the loss pain intensity.
The treatment depends on the day the pain appears. Some individuals require a combination of 2 to 3 drugs. Keeping a crises diary can help your doctor to determine more quickly the necessary drug combination.

Surgical treatment

Surgery is rarely used in this type of headache. However, if the patient does not respond to any treatment and crises always occur on the same side of the head, he can resort to surgery.
The procedure consists of cutting the nerve that sends painful signals to the face. Another type of treatment is represented by radiotherapy; a high intensity beam focused on the trigeminal nerve is used, cutting off the transmission of painful signals to the facial nerve. There is litlle information in the researches about the effectiveness of these procedures, so that they are required very rarely.

Other forms of treatment

Although medication can effectively control burst headaches and reduce the number of cycles, there are other forms of treatment as well, such as oxygen therapy.
Oxygen therapy consists of the administration of oxygen 100% by mask, immediately after the onset of the crisis and it leads in most of cases to the disappearance of pain in 10 to 20 minutes. This type of treatment can prevent the occurence of some additional headaches during a cycle. However, if they recur, the treatment must be repeated immediately after the onset of the burst. This treatment is most effective in people under the age of 50 years to whom burst headache occur occasionally.
Oxygen therapy does not prevent burst headaches, it only stops the pain temporarily. For this type of treatment the patient needs an oxygen tube which must be always close to him; this can be seen by some people as an inconvenience.




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