Teshamae Monteith, MD, Assistant Professor of Clinical Neurology, Chief of the Headache Division Program, Director of the Headache Fellowship, University of Miami Health, Department of Neurology, talks about cluster headaches and potential treatment option for patients suffering from this condition.
Interview conducted by Ivanhoe Broadcast News in November 2017.
A lot of us suffer from the occasional headache but we’re talking about something called cluster headaches, give us an idea there are different kinds of headaches right?
Dr. Monteith: Cluster headache is considered the most painful of condition known to man, worse than childbearing. I have actually had patients that have been shot or had fractures that weren’t bothered by it, because they’ve had cluster headaches. We often tell patients to rate it on a scale one to ten, ten being the worst pain imaginable. And when it comes to cluster headache, that pain scale almost has to be rewritten to actually describe what a patient with cluster headache is going through.
Before we get to what it is or what it affects … How many people suffer from cluster headaches, do you know nationally and does it affect one gender over the other more?
Dr. Monteith: Yes. Cluster headache affects one in a thousand people in the United States. And there’s certainly a male preponderance of cluster headache. But as we’re finding, women have more cluster headaches than previously recognized. Cluster headache is often taught as a disorder that affects mostly men, but that might be leading to a misdiagnosis in women. The average person is diagnosed seven years after the initial onset of a cluster headache, so it’s important to remember that women get affected too.
They seem to live with the pain a little bit longer? Describe what a cluster headache is.
Dr. Monteith: It’s a primary headache disorder similar to migraine. There are a number of primary headache disorders; it falls under the class of headaches called trigeminal autonomic cephalgias. It’s a one-sided headache that essentially occurs multiple times a day, very severe, and it’s associated with activation of the so-called “trigeminal autonomic reflex”. The parasympathetic system is involved and results in red eyes, droopy eyelids, running nose, teary eyes, and sometimes red ears. Cluster headache causes a lot of agitation during the painful spells.
Does it only when you say one side does that mean only one side would be the runny eyes?
Dr. Monteith: Yes, the same side as the pain.
How long do these last because the way Heather was describing it she was calling it cycles. So what does that mean exactly?
Dr. Monteith: Right, the individual attack can last up to three hours but then it can occur multiple times a day. So I think she mentioned three to five on average per day. The attacks occur in periods called bouts. During the bouts, the cluster attacks occur nearly every day for weeks to months.
So these are completely debilitating?
Dr. Monteith: Absolutely. I mean you really can’t work or do anything productive when you’re feeling like this.
Do we know what triggers this or what are you finding thus far in your research about cluster headaches?
Dr. Monteith: The exact mechanism of cluster headaches remains unknown. Based on brain imaging for example, we know that the dysregulation of the posterior hypothalamus occurs. Cluster headache is influenced by sleep cycles and circadian rhythms. There’s elevation of a neuropeptide called CGRP which is also elevated in migraine attacks.
There is some biology that we were able to then translate into potential treatment for patients, but the exact mechanism is still a mystery.
With migraines I’ve heard sometimes they’re associated with hormonal changes, this is completely different.
Dr. Monteith: Yes, this is completely different.
If you could tell us what are some of the treatments that you’ve been using up to this point. Basically has it been prescription medication? And why does the oxygen tank seem to work for her?
Dr. Monteith: It’s not clear exactly why oxygen works but we know that it’s effective. It’s not effective for every patient that has cluster headache. Some patients may even say the oxygen only delays the attack. So they take the oxygen, it seems to help for a little bit, but then they may have a worse attack a little bit later on. For most patients that have cluster headaches, oxygen is actually pretty effective. It’s not the easiest thing to get the oxygen or once you have the oxygen to carry it around, so that’s a problem. Oxygen falls under the category of abortive treatment. There are other abortive treatments such as sumatriptan; a triptan that’s used, similar to what’s used for treatment of migraine headaches. It’s also effective for patients with cluster headache. The problem with sumatriptan is that if you’re having four or five clusters a day you can’t use injectable sumatriptan four or five times per day, so that becomes a problem. The cost also becomes a problem; insurances often don’t want to pay for sumatriptan daily while the patient is going through their cluster periods.
You have given Heather injections?
Dr. Monteith: Yeah. Greater occipital nerve blocks can be very effective, there’s randomized control evidence supporting the use of nerve blocks. That’s really one of the first line treatments for patients. We often use lidocaine and steroid. It’s a simple injection that might be very helpful in reducing the severity, the frequency and the duration of the bout. There are other treatments. Oral steroids are sometimes used. A blood pressure called verapamil is used. Verapamil can be a problem if you have low blood pressure and can cause swelling and constipation. Lithium is sometimes used but lithium is associated with intolerable side effects and complications to thyroid and kidney for example. We don’t have a lot of wonderful treatments for the prevention of cluster headache.
So when you’re talking about a nonprescription medication talk to us about this device gammaCore. What is it and how does it work?
Dr. Monteith: The gammaCore is a noninvasive vagal nerve stimulator that can be obtained with a prescription. It’s a device that is associated with relatively little side effects and no serious side effects. It works by stimulating the vagus nerve, which has many functions throughout the body and one of them is transmitting pain. The idea of stimulating the nerve to disrupt the pain signal is a way of potentially helping patients abortively so while they’re actually having an attack. The patient may get benefits as early as fifteen minutes. That’s what the clinical trial showed. It might be useful if for example you’re not walking around without your oxygen or if you’ve already taken Sumatriptan and you want to try something else. There’s not a preventive indication right now.
And this seems to be more portable for the patient, more convenient to use. Is there an adjustment and what are they adjusting?
Dr. Monteith: Yes, they are adjusting the level of stimulation. Each patient has a different level in which they will respond to. That’s something that’s a little bit personal and the patients will have to sort that out. But once they get to that ideal level of stimulation, then potentially it’s something that actually may be very effective for the patient.
And they just apply it to that area?
Dr. Monteith: Yes. They use the gel and they apply it and allow the stimulation to occur for two minutes at a time. They are advised to do 3 consecutive 2 minute stimulations at the onset of pain. If the pain still persists after a 3 minute break, then can do another cycle. Twenty four stimulations is the maximum amount throughout the day. It’s an exciting new innovation for a condition that is so incredibly disabling.
And they have found in the clinical trial that it is FDA approved.
Dr. Monteith: It is FDA approved for acute treatment of episodic cluster headaches. It is not approved for chronic cluster headache. It was also recently approved for treatment of acute migraine attacks.
So it definitely is available and it seems to work in some patients and what is your hope … What is like on the horizon or something that you’re working on or hoping for to hopefully get rid of these cluster headaches?
Dr. Monteith: We are trying to understand that underlying mechanism of cluster headaches. I think we need to sort it out. If we don’t have a very clear understanding of what causes cluster headaches, then treatment options will remain limited. I think that we need more research for cluster headaches; certainly our patients that suffered from cluster headaches deserve it. That’s the first thing. In addition to treatments, I think that the world needs to understand what these patients go through because they’re certainly suffering.
No doubt about it.
Dr. Monteith: There are a number of other clinical studies. There’s a CGRP antibody that’s being studied for cluster headaches. We mentioned that there’s elevation of CGRP also associated with cluster attacks similar to migraines. So potentially blocking that pathway with an antibody may be useful and that’s under clinical investigation. There’s sphenopalatine ganglion (SPG) stimulation that is more invasive than the noninvasive vagal nerve stimulator but may be another potential option. There’s certainly momentum in the field, but cluster headache remains a condition that’s under studied and underfunded.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Kai Hill
Department of Neurology
305-243-6732
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