Vascular headache

Vascular headache is headache produced by dilatation of cerebral arteries ¹. Migraine is the most common vascular headache.

Vascular headaches include ¹:

• Migraine
  • Classic migraine
  • Common migraine
  • Complicated migraine
• Cluster headache
• Toxic vascular headache

In migraine, cluster headache, and toxic vascular headache, pain is produced by dilation of extracerebral arteries ¹. Patients with migraine suffer from recurrent attacks of headaches that vary widely in intensity, frequency, and duration. The headache is commonly throbbing and unilateral in onset and may vary from side to side. It is often associated with anorexia, nausea, or vomiting. Migraine is more common in females and usually begins in childhood or adolescence. The disorder is often familial. The duration of pain is variable but usually hours to days. Some patients note an association of headache with physiologic or environmental factors.

A minority of patients with migraine experience conspicuous transient neurologic symptoms preceding or accompanying the headache. These are termed “classic” migraine headaches. The symptoms are a result of vascular ischemia in localized arterial distributions and are usually visual, but symptoms such as ophthalmoplegia or hemiplegia can occur and are termed “complicated” migraine. Rarely, cerebral ischemia in migraine can be of sufficient magnitude to produce an infarction. The incidence of stroke is increased in the migraine population. Patients with common migraine do not experience conspicuous prodromal symptoms but may report vague autonomic or psychic symptoms. Common migraine can be bilateral.

Patients with cluster headache experience unilateral and usually periorbital, intense and severe pain often described as burning or boring. The pain lasts from minutes to hours, often waking the patient from sleep. It occurs in clusters of weeks to months, followed by variable periods of remission. Cluster is associated with unilateral autonomic symptoms such as facial flushing, conjunctival injection and lacrimation, rhinorrhea, and less commonly, Horner’s syndrome. Patients are usually males in the fourth or fifth decade, and the disorder is strongly associated with a smoking history.

Toxic vascular headache can result from many physiologic or environmental factors that produce vasodilation. Fever is the most common. Drugs including nitrates and other vasodilators, indomethacin, and oral progestational agents can cause this type of headache, as can withdrawal from pharmacologic agents such as ergots, caffeine, amphetamines, phenothiazines, or alcohol. Hypoxia, either as a result of pulmonary disease or altitude, can lead to headache.

Vascular headache causes

Vascular headaches are caused by blood vessel abnormalities, which by turn constrict and open blood vessels in the head.

Vascular headaches include ¹:

• Migraine
  • Classic migraine
  • Common migraine
  • Complicated migraine
• Cluster headache
• Toxic vascular headache

Migraine

A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities.

Many people who have migraines feel vaguely unwell for a day or two beforehand.

For some people, a warning symptom known as an aura occurs before or with the headache. An aura can include visual disturbances, such as flashes of light or blind spots, or other disturbances, such as tingling or pins and needles on one side of the face or in an arm or leg and difficulty speaking. This can happen before or during a migraine.

When the headache starts, it is usually severe. Your heads throbs, and it might hurt to see bright lights or hear noises. You might feel sick, and you might vomit. This can last anywhere between a few hours and a few days.

Medications can help prevent some migraines and make them less painful. The right medicines, combined with self-help remedies and lifestyle changes, might help.

Nobody knows what causes migraines. Researchers believe that migraine has a genetic cause. They can run in families, but don’t have to. There are also a number of factors that can trigger a migraine. These factors vary from person to person, and they include

• Stress and changes of routine
• Anxiety
• Hormonal changes in women
• Oral contraceptive pill for women
• Bright or flashing lights
• Loud noises
• Strong smells
• Medicines
• Too much or not enough sleep
• Sudden changes in weather or environment
• Overexertion (too much physical activity)
• Tobacco
• Caffeine or caffeine withdrawal
• Skipped meals
• Medication overuse (taking medicine for migraines too often)

Some people have found that certain foods or ingredients can trigger migraine headaches, especially when they are combined with other triggers. These foods and ingredients include

• Alcohol (especially red wine and beer)
• Chocolate
• Aged cheeses
• Monosodium glutamate (MSG)
• Some fruits and nuts
• Fermented or pickled goods
• Yeast
• Cured or processed meats

Cluster headache

Cluster headaches are relatively rare, and are characterized by brief (15 to 180 minutes) episodes of severe headaches that occur in a group, or cluster, with associated autonomic symptoms ². Although cluster headaches are less common than migraines and tension-type headaches, an estimated 500,000 Americans experience them at least once in a lifetime ⁸. The age of onset of cluster headaches varies, with 70 percent of patients reporting onset before 30 years of age ⁹.

People who get cluster headaches find they have frequent headaches for weeks or months, then none for a long time. In a few people, the headaches come on continuously. They happen more in the night than during the day, and often at the same time each night. They are very painful.

Cluster headaches occur on one side of the face, often around or behind the eye. They can last anywhere between 15 minutes and three hours. They can happen as often as 8 times in one day, or once every couple of days. Many people also have, on the same side of the face:

• a red and weepy eye
• a drooping or swollen eyelid
• a runny or blocked nose
• sweaty skin.

They might also feel restless or agitated.

Nobody knows what causes cluster headaches. Cluster headaches sometimes run in families. People who get them are more likely to smoke heavily, drink heavily, drink a lot of caffeine and feel a lot of stress, but they can happen to anybody.

The long delay in diagnosis reported by patients who have cluster headaches is important. Only 25 percent of patients with cluster headaches are diagnosed correctly within one year of symptom onset, and more than 40 percent report a delay in diagnosis of five years or longer ⁸. The most common incorrect diagnoses reported in one study were migraine (34 percent), sinusitis (21 percent), and allergies (6 percent) ¹⁰. Family history appears to have a role in some cases. A number of comorbidities are associated with cluster headaches, including depression (24 percent), sleep apnea (14 percent), restless legs syndrome (11 percent), and asthma (9 percent) ¹⁰. Depression is an important diagnosis, because many individuals who have cluster headaches report suicidal thoughts, and 2 percent of patients in one study had attempted suicide ¹¹.

International Classification of Headache Disorders, 2nd ed. Diagnostic Criteria for Cluster Headache ¹²

At least five episodes fulfilling the following criteria:

• Severe or very severe unilateral orbital, supraorbital, or temporal pain lasting 15 to 180 minutes if untreated
• Headache is accompanied by at least one of the following ipsilateral autonomic symptoms: conjunctival injection or lacrimation, nasal congestion or rhinorrhea, eyelid edema, forehead and facial sweating, miosis or ptosis, restlessness or agitation
• Headache episodes occur from one every other day to eight per day

Not attributable to another disorder.

Episodic cluster headache

• Fulfills all of the above criteria
• At least two cluster periods lasting seven to 365 days and separated by pain-free remissions of more than one month

Chronic cluster headache

• Fulfills all of the above criteria
• Episodes recur for more than one year without remission periods or with remission periods lasting less than one month

Toxic vascular headache

A toxic headache is the least common type of vascular headache that usually comes from a fever from acute illnesses such as measles, mumps, pneumonia and tonsillitis. Common hazards in our environment also cause toxic headaches with exposure. These include chemicals, fumes, pollution, allergens and other health hazards. These toxins can be found in our communities, workplaces, and homes.

A chemical factor from the outside or inside of your body can result in a toxic headache. Internal body sources are harder to identify, but usually arise when an organ fails to function properly. When this happens, in the bowels, liver or kidneys for example, the body builds up toxicity because waste products are not being removed as they should. The increase in toxicity levels may cause a headache. To treat these headaches, the organ dysfunction must be corrected to eliminate toxic waste.

Toxic headaches are considered an environmental illness when it is caused by exposure to a toxin. These headaches can be caused by exposure to toxic chemicals, including lead, insecticides, organophosphate pesticides, chemical solvents, acetaldehyde from alcohol (a hangover), carbon tetrachloride, and some household cleaners. This often happens through destabilizing the magnesium metabolism of the cell, which triggers a cascade of biological and neurological reactions, culminating in a migraine, toxic headache, or worse (such as neurological damage). The effect of alcohol can be magnified by “congeners” from alcohol fermentation.

Several common chemicals are toxic headache culprits. Nitrite compounds dilate blood vessels, causing dull and pounding headaches with repeat exposure. Nitrite is found in dynamite, heart medicine and it is a chemical used to preserve meat. Poisons, like carbon tetrachloride, insecticides and lead can cause headaches with exposure also. Ingesting lead paint or having contact with lead batteries can cause headaches.

Caffeine can be used to cure a headache by constricting dilated arteries. However, caffeine is also a chemical headache inducer for individuals who ingest lots of caffeine and are trying to cut back. Toxic shock syndrome can lead to headaches due to the staphylococcus aureus bacteria infection. Headaches are also a symptom of carbon monoxide poisoning. Toxic and polluted air can lead to toxic headaches with constant exposure.

Toxic headaches are treated by determining the cause of the headache and treating or removing it. But often the cause of a toxic headache is unknown because symptoms depend on the environmental or bodily cause. Symptoms may not appear for years or they can become gradually with more exposure. Many times the source of the headache will not be recognized until your symptoms continue or they only appear at specific places or times. Toxic headaches due to environmental causes are usually diagnosed by taking an exposure history, listing details about the places you frequent most days. Treatments vary based on symptoms and the cause of the headache.

Vascular headache symptoms

Cluster headache symptoms

Patients with cluster headache experience unilateral and usually periorbital, intense and severe sharp pain often described as burning or boring, but some report that it can also be pulsating and pressure-like. Although pain can occur on both sides of the head, most patients report unilateral pain. Pain most commonly occurs in the retro-orbital area, followed by the temporal region, upper teeth, jaw, cheek, lower teeth, and neck ⁹. Cluster headache is associated with unilateral autonomic symptoms such as facial flushing, forehead sweating, eyelid edema, nasal congestion, rhinorrhea, lacrimation, conjunctival injection and less commonly, Horner’s syndrome. There tend to be several (up to eight) episodes in the same day, with each episode lasting between 15 and 180 minutes ¹². In the episodic form (80 to 90 percent of cases), episodes occur daily for a number of weeks followed by a period of remission ¹². On average, a period of cluster headaches lasts six to 12 weeks, with remission lasting up to 12 months.4 In the chronic form (10 to 20 percent of cases), episodes occur without significant periods of remission ¹². Patients are usually males in the fourth or fifth decade, and the disorder is strongly associated with a smoking history.

Toxic vascular headache  

Toxic vascular headache can result from many physiologic or environmental factors that produce vasodilation. Fever is the most common. Drugs including nitrates and other vasodilators, indomethacin, and oral progestational agents can cause this type of headache, as can withdrawal from pharmacologic agents such as ergots, caffeine, amphetamines, phenothiazines, or alcohol. Hypoxia, either as a result of pulmonary disease or altitude, can lead to headache.

Migraine symptoms

Migraines, which often begin in childhood, adolescence or early adulthood, can progress through four stages: prodrome, aura, attack and post-drome. Not everyone who has migraines goes through all stages.

Prodrome

Many people who have migraines feel vaguely unwell for a day or two beforehand.

One or two days before a migraine, you might notice subtle changes that warn of an upcoming migraine, including:

• Constipation
• Mood changes, from depression to euphoria
• Food cravings
• Neck stiffness
• Increased thirst and urination
• Frequent yawning

Aura

For some people, aura might occur before or during migraines. Auras are reversible symptoms of the nervous system. They’re usually visual, but can also include other disturbances. Each symptom usually begins gradually, builds up over several minutes and lasts for 20 to 60 minutes.

Examples of migraine aura include:

• Visual phenomena, such as seeing various shapes, bright spots or flashes of light
• Vision loss
• Pins and needles sensations in an arm or leg
• Weakness or numbness in the face or one side of the body
• Difficulty speaking
• Hearing noises or music
• Uncontrollable jerking or other movements

Attack

A migraine usually lasts from four to 72 hours if untreated. How often migraines occur varies from person to person. Migraines might occur rarely or strike several times a month.

During a migraine, you might have:

• Pain usually on one side of your head, but often on both sides
• Pain that throbs or pulses
• Sensitivity to light, sound, and sometimes smell and touch
• Nausea and vomiting

Post-drome

After a migraine attack, you might feel drained, confused and washed out for up to a day. Some people report feeling elated. Sudden head movement might bring on the pain again briefly.

Vascular headache diagnosis

To make a vascular headache diagnosis, your doctor will:

• Take your medical history
• Ask about your symptoms
• Do a physical and neurological exam

An important part of diagnosing vascular headaches or migraines is to rule out other medical conditions which could be causing the symptoms.

The American College of Emergency Physicians has determined that response to pain relief therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache ¹³. No prospective randomized controlled trials, evidence from meta-analyses, randomized controlled trials, or well-designed cohort studies support or refute the practice of using response to pain relief therapy in nontraumatic headaches as an indicator of potential underlying pathology.

If your condition is unusual, complex or suddenly becomes severe, tests to rule out other causes for your pain might include:

• MRI. An MRI scan uses a powerful magnetic field and radio waves to produce detailed images of the brain and blood vessels. MRI scans help doctors diagnose tumors, strokes, bleeding in the brain, infections, and other brain and nervous system (neurological) conditions.
• CT scan. A CT scan uses a series of X-rays to create detailed cross-sectional images of the brain. This helps doctors diagnose tumors, infections, brain damage, bleeding in the brain and other possible medical problems that may be causing headaches.
• Lumbar puncture. Lumbar puncture is useful for identifying infection, the presence of red blood cells (which suggests bleeding), and abnormal cells associated with some central nervous system (CNS) malignancies. In adults with suspected subarachnoid hemorrhage, it is important to perform lumbar puncture to check for blood or xanthochromia. Computed tomography of the head should be performed before lumbar puncture, even if the results of neurologic examination are normal, because there is a risk of central herniation of the brain even in the absence of physical examination findings of subarachnoid hemorrhage. In one supporting study, 5 percent of patients presenting to an emergency department with suspected subarachnoid hemorrhage and a normal neurologic examination had early intracranial herniation or midline shift ¹⁴.

Medical History

Thunderclap headache, which is characterized by sudden-onset headache pain, with peak intensity occurring within several minutes, requires prompt evaluation. Subarachnoid hemorrhage, hypertensive emergencies, vertebral artery dissections, and acute angle–closure glaucoma can also present this way ¹⁵.

Use of illicit drugs, including cocaine and methamphetamine, can increase the risk of intracranial bleeding or stroke. Prescription or over-the-counter medications such as aspirin, other nonsteroidal anti-inflammatory drugs, anticoagulants, and glucocorticoids increase the risk of intracranial bleeding.

A history of human immunodeficiency virus infection or other immunosuppressive conditions in patients with headache may suggest a brain abscess, meningitis, or malignancy of the central nervous system (CNS) ¹⁶. The presence of a coexisting infection in the lungs, sinuses, or orbital areas may precede and cause a CNS infection.

A patient who reports the worst headache of his or her life, especially if the patient is older than 50 years, or who has a headache that occurs with exertion (including sexual intercourse) could be experiencing intracranial hemorrhage or carotid artery dissection ¹⁷. Prompt investigation is required for any headaches associated with neurologic findings, including changes in mental status, seizures, and visual disturbances. Additional red flag symptoms and signs are listed in Table 1 above.

Physical Examination

Neurologic abnormalities require evaluation and are particularly concerning in association with acute headache. Abnormalities are one of the best predictors of central nervous system pathology ¹⁸. A focal neurologic deficit should not be attributed to migraine headache unless a similar pattern has occurred with a previous migraine. By definition, aura associated with migraine lasts 60 minutes or less. Therefore, headache with aura-like symptoms should not be assumed to be benign or a primary headache when aura-like symptoms are present for more than 60 minutes.

Abnormal findings on examination can be pronounced, such as meningismus or unilateral vision loss, or subtle, such as extensor plantar response or unilateral pronator drift. Obtundation or confusion suggests a dangerous headache because these signs do not occur with benign or primary headache.

Patients with headache and fever, papilledema, or severe hypertension (systolic pressure greater than 180 mm Hg or diastolic pressure greater than 120 mm Hg) require evaluation for central nervous system infection and increased intracranial pressure. Patients also should be evaluated to determine if their blood pressure should be lowered to safer levels to avoid intracranial hemorrhage from malignant hypertension. Contusions and facial or scalp lacerations increase the likelihood of associated intracranial hemorrhage ⁵.

Diagnostic testing

Neuroimaging is indicated for all patients who present with signs or symptoms of dangerous headache, because they are at increased risk of intracranial pathology. Although considerable debate exists about the optimal way to perform neuroimaging for acute headaches, the American College of Radiology has made a few specific recommendations (Table 2) ¹⁹.

Table 2. American College of Radiology Recommendations for Neuroimaging in Patients with Headache

Clinical features	Recommended imaging modality
Headache in immunocompromised patients	MRI of the head with and without contrast media
Headache in patients older than 60 years with suspected temporal arteritis	MRI of the head with and without contrast media
Headache with suspected meningitis	CT or MRI of the head without contrast media
Severe headache in pregnancy	CT or MRI of the head without contrast media
Severe unilateral headache caused by possible dissection of the carotid or arterial arteries	MRI of the head with and without contrast media, MRA of the head and neck, or CTA of the head and neck
Sudden onset or severe headache; worst headache of the patient’s life	CT of the head without contrast media; CTA of the head with contrast media, MRA of the head with or without contrast media, or MRI of the head without contrast media

Abbreviations: CT = computed tomography; CTA = computed tomographic angiography; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging.

[Source ¹⁹ ]

Vascular headache treatment

Migraine treatment

Migraine treatment is aimed at stopping symptoms and preventing future attacks.

Many medications have been designed to treat migraines. Medications used to combat migraines fall into two broad categories:

• Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms.
• Preventive medications. These types of drugs are taken regularly, often daily, to reduce the severity or frequency of migraines.

Your treatment choices depend on the frequency and severity of your headaches, whether you have nausea and vomiting with your headaches, how disabling your headaches are, and other medical conditions you have.

Medications for relief

Medications used to relieve migraine pain work best when taken at the first sign of an oncoming migraine — as soon as signs and symptoms of a migraine begin. Medications that can be used to treat it include:

• Pain relievers. These over-the-counter or prescription pain relievers include aspirin or ibuprofen (Advil, Motrin IB, others). When taken too long, these might cause medication-overuse headaches, and possibly ulcers and bleeding in the gastrointestinal tract. Migraine relief medications that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain.
• Triptans. These are prescription drugs such as sumatriptan (Imitrex, Tosymra) and rizatriptan (Maxalt) are prescription drugs used for migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine. They might not be safe for those at risk of a stroke or heart attack.
• Dihydroergotamines (D.H.E. 45, Migranal). Available as a nasal spray or injection, these are most effective when taken shortly after the start of migraine symptoms for migraines that tend to last longer than 24 hours. Side effects can include worsening of migraine-related vomiting and nausea. People with coronary artery disease, high blood pressure, or kidney or liver disease should avoid dihydrogergotamines.
• Lasmiditan (Reyvow). This new oral tablet is approved for the treatment of migraine with or without aura. In drug trials, lasmiditan significantly improved pain as well as nausea and sensitivity to light and sound. Lasmiditan can have a sedative effect and cause dizziness, so people taking it are advised not to drive or operate machinery for at least eight hours. Lasmiditan also shouldn’t be taken with alcohol or other drugs that depress the central nervous system.
• Opioid medications. People who have migraines who can’t take other migraine medications, narcotic opioid medications, especially those that contain codeine, might help. Because they can be highly addictive, these are usually used only if no other treatments are effective.
• Anti-nausea drugs. These can help if your migraine with aura is accompanied by nausea and vomiting. Anti-nausea drugs include chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro). These are usually taken with pain medications.

Preventive medications

Medications can help prevent frequent migraines. Your doctor might recommend preventive medications if you have frequent, long-lasting or severe headaches that don’t respond well to treatment.

Preventive medication is aimed at reducing how often you get a migraine how severe the attacks are and how long they last. Options include:

• Blood pressure-lowering medications. These include beta blockers such as propranolol (Inderal, Innopran XL, others) and metoprolol tartrate (Lopressor). Calcium channel blockers such as verapamil (Calan, Verelan, others) can be helpful in preventing migraines with aura.
• Antidepressants. A tricyclic antidepressant (amitriptyline), can prevent migraines. Because of the side effects of amitriptyline, such as sleepiness and weight gain, other antidepressants might be prescribed instead.
• Anti-seizure drugs. Valproate (Depacon) and topiramate (Topamax) might help you have less frequent migraines, but can cause side effects such as dizziness, weight changes, nausea and more.
• Botox injections. Injections of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.
• Calcitonin gene-related peptide (CGRP) monoclonal antibodies. Erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy) and galcanezumab-gnlm (Emgality) are newer drugs approved by the Food and Drug Administration to treat migraines. They’re given monthly by injection. The most common side effect is a reaction at the injection site.

Lifestyle and home remedies

When symptoms of migraine start, try heading to a quiet, darkened room. Close your eyes and rest or take a nap. Place a cool cloth or ice pack wrapped in a towel or cloth on your forehead or at the back of your neck.

Other practices that might soothe migraine with aura pain include:

• Try relaxation techniques. Biofeedback and other forms of relaxation training teach you ways to deal with stressful situations, which might help reduce the number of migraines you have.
• Develop a sleeping and eating routine. Don’t sleep too much or too little. Set and follow a consistent sleep and wake schedule daily. Try to eat meals at the same time every day.
• Drink plenty of fluids. Staying hydrated, particularly with water, might help.
• Keep a headache diary. Continue recording in your headache diary even after you see your doctor. It will help you learn more about what triggers your migraines and what treatment is most effective.
• Exercise regularly. Regular aerobic exercise reduces tension and can help prevent a migraine. If your doctor agrees, choose aerobic activity you enjoy, such as walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches. Regular exercise can also help you lose weight or maintain a healthy body weight, and obesity is thought to be a factor in migraines.

Alternative medicine

Nontraditional therapies might help with chronic migraine pain.

• Acupuncture. Clinical trials have found that acupuncture may be helpful for headache pain. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin at defined points.
• Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress, such as muscle tension.
• Cognitive behavioral therapy. Cognitive behavioral therapy may benefit some people with migraines. This type of psychotherapy teaches you how behaviors and thoughts affect how you perceive pain.
• Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur might prevent migraines or reduce their severity, though study results are mixed. Butterbur isn’t recommended because of safety concerns.

A high dose of riboflavin (vitamin B-2) may also prevent migraines or reduce the frequency of headaches. Coenzyme Q10 supplements might decrease the frequency of migraines, but larger studies are needed.

Due to low magnesium levels in some people with migraines, magnesium supplements have been used to treat migraines, but with mixed results.

Ask your doctor if these treatments are right for you. Don’t use feverfew, riboflavin or butterbur if you’re pregnant or without first talking with your doctor.

Cluster headaches treatments

There’s no cure for cluster headaches. Treatment and prevention of cluster headaches can be difficult. The usual painkillers often don’t work. The goal of treatment is to decrease the severity of pain, shorten the headache period and prevent the attacks.

There are a range of medicines that can help prevent a cluster starting. Talk to your doctor about these.

Because the pain of a cluster headache comes on suddenly and might subside within a short time, cluster headache can be difficult to evaluate and treat, as it requires fast-acting medications.

If you are in the middle of a cluster, you can reduce your chances of having a headache by getting plenty of sleep, and sleeping at the same time each night, and also by avoiding alcohol completely. You should also try to get regular sleep, avoid stress or strenuous physical activity, and avoid a high altitude.

If you get a cluster headache, then you can try:

• medicines – talk to your doctor
• oxygen through a mask
• a nasal spray of local anaesthetic.

Talk to your doctor about these.

Some types of acute medication can provide some pain relief quickly. The therapies listed below have proved to be most effective for acute and preventive treatment of cluster headache.

Acute treatments

Fast-acting treatments available from your doctor include:

• Oxygen. Briefly inhaling pure oxygen through a mask provides dramatic relief for most who use it. The effects of this safe, inexpensive procedure can be felt within 15 minutes. Oxygen is generally safe and without side effects. The major drawback of oxygen is the need to carry an oxygen cylinder and regulator with you, which can make the treatment inconvenient and inaccessible at times. Small, portable units are available, but some people still find them impractical.
• Triptans. The injectable form of sumatriptan (Imitrex), which is commonly used to treat migraine, is also an effective treatment for acute cluster headache. The first injection may be given while under medical observation. Some people may benefit from using sumatriptan in nasal spray form, but for most people this isn’t as effective as an injection and it may take longer to work. Sumatriptan isn’t recommended if you have uncontrolled high blood pressure or heart disease. Another triptan medication, zolmitriptan (Zomig), can be taken in nasal spray form for relief of cluster headache. This medication may be an option if you can’t tolerate other forms of fast-acting treatments. Oral medications are relatively slow to act and are often not useful for acute treatment of cluster headaches.
• Octreotide. Octreotide (Sandostatin), an injectable synthetic version of the brain hormone somatostatin, is an effective treatment for cluster headache for some people. But overall, it’s less effective and acts less quickly to relieve pain than triptans.
• Local anesthetics. The numbing effect of local anesthetics, such as lidocaine, may be effective against cluster headache pain in some people when given through the nose (intranasal).
• Dihydroergotamine. The injectable form of dihydroergotamine (D.H.E. 45) may be an effective pain reliever for some people with cluster headache. This medication is also available in an inhaled (intranasal) form, but this form hasn’t been proved to be effective for cluster headache.

Preventive treatments

Preventive therapy starts at the onset of the cluster episode with the goal of suppressing attacks.

Determining which medicine to use often depends on the length and regularity of your episodes. Under the guidance of your doctor, you can taper off the drugs once the expected length of the cluster episode ends.

• Calcium channel blockers. The calcium channel blocking agent verapamil (Calan, Verelan, others) is often the first choice for preventing cluster headache. Verapamil may be used with other medications. Occasionally, longer term use is needed to manage chronic cluster headache. Side effects may include constipation, nausea, fatigue, swelling of the ankles and low blood pressure.
• Corticosteroids. Inflammation-suppressing drugs called corticosteroids, such as prednisone (Prednisone Intensol, Rayos), are fast-acting preventive medications that may be effective for many people with cluster headaches. Your doctor may prescribe corticosteroids if your cluster headache condition has started recently or if you have a pattern of brief cluster periods and long remissions. Although corticosteroids might be a good option to use for several days, serious side effects such as diabetes, hypertension and cataracts make them inappropriate for long-term use.
• Lithium carbonate. Lithium carbonate (Lithobid), which is used to treat bipolar disorder, may be effective in preventing chronic cluster headache if other medications haven’t prevented cluster headaches. Side effects include tremor, increased thirst and diarrhea. Your doctor can adjust the dosage to minimize side effects. While you’re taking lithium carbonate (Lithobid), your blood will be checked regularly for the development of more-serious side effects, such as kidney damage.
• Nerve block. Injecting a numbing agent (anesthetic) and corticosteroid into the area around the occipital nerve, situated at the back of your head, might improve chronic cluster headaches. An occipital nerve block may be useful for temporary relief until long-term preventive medications take effect. It’s often used in combination with verapamil.

Other preventive medications used for cluster headache include anti-seizure medications, such as topiramate (Topamax, Qudexy XR, others).

Lifestyle and home remedies

The following measures may help you avoid a cluster headache attack during a cluster cycle:

• Stick to a regular sleep schedule. Cluster periods can begin when there are changes in your normal sleep schedule. During a cluster period, follow your usual sleep routine.
• Avoid alcohol. Alcohol consumption, including beer and wine, can quickly trigger a headache during a cluster period.

Alternative medicine

Because cluster headaches can be so painful, you may want to try alternative or complementary therapies to relieve your pain.

Melatonin has shown modest effectiveness in treating nighttime attacks. There’s also some evidence that capsaicin, used inside your nose (intranasally), might reduce the frequency and severity of cluster headache attacks.

Surgery

Rarely, doctors may recommend surgery for people with chronic cluster headaches who don’t find relief with aggressive treatment or who can’t tolerate the medications or their side effects.

Sphenopalatine ganglion stimulation involves surgery to implant a neurostimulator that’s operated by a hand-held remote controller. Some research showed quick pain relief and a lower frequency of headaches, but more studies are needed.

Noninvasive vagus nerve stimulation is another surgical option. It also uses a hand-held controller to deliver electrical stimulation to the vagus nerve through the skin. While more research is needed, some studies found that vagus nerve stimulation helped reduce the frequency of cluster headaches.

Several small studies found that occipital nerve stimulation on one or both sides may be beneficial. This involves implanting an electrode next to one or both occipital nerves.

Some surgical procedures for cluster headache attempt to damage the nerve pathways thought to be responsible for pain, most commonly the trigeminal nerve that serves the area behind and around your eye.

However, the long-term benefits of destructive procedures are disputed. Also, because of the possible complications — including muscle weakness in your jaw or sensory loss in certain areas of your face and head — it’s rarely considered.

Potential future treatments

Researchers are studying several potential treatments for cluster headache.

• Occipital nerve stimulation. In this procedure, your surgeon implants electrodes in the back of your head and connects them to a small pacemaker-like device (generator). The electrodes send impulses to stimulate the area of the occipital nerve, which may block or relieve your pain signals. Several small studies of occipital nerve stimulation found that the procedure reduced pain and frequency of headaches in some people with chronic cluster headaches.
• Deep brain stimulation. Deep brain stimulation is a promising but as yet unproven treatment for cluster headaches that don’t respond to other treatments. In this procedure, doctors implant an electrode in the hypothalamus, the area of your brain associated with the timing of cluster periods. Your surgeon connects the electrode to a generator that changes your brain’s electrical impulses and may help relieve your pain. Because this involves placing an electrode deep in the brain, there are significant risks, such as an infection or hemorrhage. Deep brain stimulation of the hypothalamus may provide relief for people with severe, chronic cluster headaches that haven’t been successfully treated with medications.

Toxic headaches treatment

Toxic headaches are treated by determining the cause of the headache and treating or removing it. But often the cause of a toxic headache is unknown because symptoms depend on the environmental or bodily cause. Symptoms may not appear for years or they can become gradually with more exposure. Many times the source of the headache will not be recognized until your symptoms continue or they only appear at specific places or times. Toxic headaches due to environmental causes are usually diagnosed by taking an exposure history, listing details about the places you frequent most days. Treatments vary based on symptoms and the cause of the headache.

References

1. Bigley GK. Headache. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 54. Available from: https://www.ncbi.nlm.nih.gov/books/NBK377
2. Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27(3):193–210.
3. Edmeads J. Emergency management of headache. Headache. 1988;28(10):675–679
4. Ramirez-Lassepas M, Espinosa CE, Cicero JJ, Johnston KL, Cipolle RJ, Barber DL. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol. 1997;54(12):1506–1509.
5. Ramchandren S, Cross BJ, Liebeskind DS. Emergent headaches during pregnancy: correlation between neurologic examination and neuroimaging. AJNR Am J Neuroradiol. 2007;28(6):1085–1087.
6. American Academy of Neurology: Lipton RB, Bigal ME, Steiner TJ, et al. Classification of primary headaches. Neurology. 2004;63(3):428.
7. Edmeads J. Emergency management of headache. Headache. 1988;28(10):675–679.
8. Torelli P, Manzoni GC. Pain and behaviour in cluster headache. A prospective study and review of the literature. Funct Neurol. 2003;18(4):205–210.
9. Rozen TD, Fishman RS. Cluster headache in the United States of America: demographics, clinical characteristics, triggers, suicidality, and personal burden. Headache. 2012;52(1):99–113.
10. Martin VT, Penzien DB, Houle TT, Andrew ME, Lofland KR. The predictive value of abbreviated migraine diagnostic criteria. Headache. 2005;45(9):1102–1112.
11. Jürgens TP, Gaul C, Lindwurm A, et al. Impairment in episodic and chronic cluster headache [published correction appears in Cephalalgia. 2011;31(6):766]. Cephalalgia. 2011;31(6):671–82.
12. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 2nd edition. Cephalalgia. 2004;24(suppl 1):9–160.
13. Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW; American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407–436.
14. Baraff LJ, Byyny RL, Probst MA, Salamon N, Linetsky M, Mower WR. Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination. Acad Emerg Med. 2010;17(4):423–428.
15. Pascual J, González-Mandly A, Martín R, Oterino A. Headaches precipitated by cough, prolonged exercise or sexual activity: a prospective etiological and clinical study. J Headache Pain. 2008;9(5):259–266.
16. Clinch CR. Evaluation of acute headaches in adults. Am Fam Physician. 2001;63(4):685–692.
17. Rothman RE, Keyl PM, McArthur JC, Beauchamp NJ Jr, Danyluk T, Kelen GD. A decision guideline for emergency department utilization of non-contrast head computed tomography in HIV-infected patients. Acad Emerg Med. 1999;6(10):1010–1019.
18. American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Ann Emerg Med. 2002;39(1):108–122.
19. Strain JD, Strife JL, Kushner DC, et al. Headache. American College of Radiology. ACR appropriateness criteria. Radiology. 2000;215(suppl):855–860.