Beam headache

Beam headache is the primary form of cephalgia, manifested by attacks of very intense severely unilateral pain of orbital, supraorbital, temporal or mixed localization, lasting 15-180 minutes, occurring daily at a frequency of once every 2 days up to eight times a day. Attacks on the side of pain are accompanied by one or more of the following symptoms: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, sweating forehead and face, miosis, ptosis, eyelid edema. The clinical picture is the decisive criterion for diagnosis. To stop the attack use inhalation of oxygen, triptans, ergotamine or a combination thereof. For the prevention of attacks prescribed verapamil, metisergid, lithium valproate or a combination thereof.

The incidence of cluster headache in the population is low - 0.5-1%. Men suffer 3-4 times more often than women, the debut of the disease occurs in 20-40 years. In 5% of patients, the disease is hereditary.

In the US, the incidence is 0.4%. In most cases, the bundle headache has the character of episodic seizures; during the cluster periods for 1-3 months the patient experiences daily seizures (from one or more) of the bundle headache, then a prolonged remission occurs from several months to several years. In some patients, cluster headache occurs without periods of remission.

The pathophysiology of cluster headache is not fully understood, but its periodicity indicates hypothalamic dysfunction. The use of alcohol provokes an attack of headache during the cluster period, but not during remission.

Synonyms - beam migraine (English cluster - bundle), histamine cephalgia, Horton's syndrome, Harris's migraine neuralgia, ciliary neuralgia, erythromelalgia of the head, erythroprosoplegia Binga.

[1]

What causes a headache?

It is shown that the cluster period (including the first "bundle") can occur after a violation of the usual daily rhythm: the change of time zones during air flights, sleepless nights, daily work schedule, etc. During a painful "beam", as well as in a chronic form headache attacks can be triggered by taking alcohol, histamine or nitroglycerin. There is a close association of attacks of bundle headache and night sleep: night attacks are considered obligate for this form of cephalalgia. It is curious that during the period of remission, no provocateurs are able to cause an onset of a bundle headache.

Symptoms of a bundle headache

The most typical characteristics of the bundle headache are its unbearable nature, repeated repetition during the day and night, bright vegetative manifestations on the face, as well as a peculiar course of the disease - the appearance of pain attacks by series, or "bundles". The duration of the beam is from several weeks to several months with a clearly marked remission lasting from several months to several years (an average of 2-3 years). In 10-15% of patients chronic course without remissions is noted, in 27% only one episode of the headache develops. For many patients, the seasonality of exacerbations is typical: in spring and in autumn. Unlike patients with migraine, a patient with a cluster headache does not feel like going to bed or secluded in a quiet darkened room, he is excited and restlessly pacing the room.

Pain is more often localized around the eye, in the brow, temporal or in several areas, but it can spread to other areas of the head. Because of unbearable pain, most patients have motor anxiety, aggression and agitation during the attack, and there are known attempts at suicide during an attack of a bundle headache. During a painful "bundle", pain always comes from the same side. Vegetative symptoms, including nasal congestion, rhinorrhea, lacrimation, face redness and Horner's syndrome, are noted on the same side as the headache.

In patients with a bundle headache, the so-called "lion and mouse" syndrome is often noted. Thus, men with this form of cephalgia usually have a characteristic appearance: athletic manly physique, thickened with telangiectasias and facial wrinkles expressed by facial skin - "the face of a lion". At the same time, they are characterized by internal stiffness, indecision, they often have difficulty in making decisions (the "heart of the mouse").

Clinical varieties of bundle headache

Most often observed episodic form of beam headache, less often - chronic, when remissions are either absent altogether, or do not exceed 1 month. Chronic form of bundle headache (10-15% of cases) can occur de novo or occur from an episodic form. In some patients, the transition from a chronic to an episodic form is noted. Some patients described a combination of beam headache and trigeminal neuralgia.

[2], [3], [4], [5]

Diagnosis of Beam Headache

The diagnosis of "bundle headache" is based on a typical clinical picture (strictly one-sided pains in the face and head half, accompanied by vegetative manifestations on the face: lacrimation, rhinorrhea, etc.) and on the characteristic course of the disease (alternation of pain periods, "bundles", with light intervals, remissions). Additional criteria for beam headache are its unbearable nature and motor excitement, as well as the occurrence of seizures during night sleep. Traditional methods of research (EEG, MRI, USDG) are not informative. Diagnostic criteria for beam headache are presented below.

3.1. Beam (cluster) headache (ICG-4)

• A. At least five seizures that meet the BD criteria.
• B. Intensive or extremely intense unilateral pain of orbital, supraorbital and / or temporal localization of 15-180 min without treatment.
• C. Headache is accompanied by at least one of the following symptoms on the side of the pain:
  • Injection of conjunctiva and / or lacrimation;
  • nasal congestion and / or rhinorrhea;
  • the swelling of the eyelids;
  • sweating of the forehead and face;
  • miosis and / or ptosis;
  • a feeling of anxiety (inability to be at rest) or agitation.
• D. The frequency of seizures - from once every 2 days to eight times a day.
• E. Not related to other causes (abnormalities).

Cluster headache is differentiated with other syndromes with unilateral headache and vegetative components, in particular chronic paroxysmal hemicrania with more frequent (> 5 per day) and shorter (usually several minutes) attacks and with a permanent hemicrania characterized by a moderately prolonged unilateral headache with a stratification of short episodes of more intense pain. These two types of headaches, unlike cluster headaches and migraines, are effectively stopped by indomethacin, but at the same time, they react poorly to other NSAIDs.

[6], [7]

Treatment of bundle headache

Acute attacks of bundle headache can be suppressed by parenteral administration of the preparation of the tryptane group or dihydroergotamine, and by inhalation of 100% O2. Since cluster headache, due to the frequency and intensity of seizures, significantly reduces work capacity, patients are shown preventive drug therapy. For example, a single dose of prednisone inwards (60 mg) will provide rapid protection at a time until the effect of prophylactic drugs with a slower onset of action (verapamil, lithium, methysergide, valproate, topiramate) appears.

During the painful "beam" patients should avoid possible provoking factors: do not take alcohol and vasodilators, observe sleep-wakefulness. When cupping attacks of bundle headache, as well as migraine attacks, the greatest effect is possessed by tryptans (sumatriptan, eletriptan, zolmitriptan, etc.). Given the frequency of attacks with a headache (more than once a day) and the possibility of side effects, with the use of triptans should be careful: do not exceed the permissible daily dose of drugs.

Basic approaches to treatment of beam headache

• Treatment of an attack (abortive therapy):
  • inhalation of oxygen;
  • triptans;
  • lidocaine intranasally.
• Prevention of an attack:
  • verapamil (80-240 mg / day);
  • lithium carbonate (300-900 mg / day);
  • valproic acid (600-2000 mg / day);
  • Topiramate (50-100 mg / day);
  • gabapentin (1,800 2,400 mg / day).
• Surgery:
  • radio-frequency thermocoagulation of trigeminal ganglion;
  • radiofrequency rhizotomy:
  • microvascular decompression;
  • Neurostimulation.

With episodic form and relatively easy flow, lithium carbonate and verapamil have a good effect, if necessary, a combination of these drugs is possible. With more severe current (more than five attacks per day, longer duration of pain beam - more than 2 months), the use of anticonvulsants and gabapentin is indicated.

Difficulty is the treatment of a chronic form of bundle headache. If these approaches are ineffective in chronic form, glucocorticoids may be used. Along with surgical methods for the treatment of chronic form of chronic headache resistant to other forms of therapy, neurostimulation methods are used: deep stimulation of the posterior hypothalamic region, stimulation of the large occipital and vagus nerve (Shoenen, 2007). According to the first few studies conducted in Europe, the duration of remission after hypothalamic neurostimulation can reach 9 months. Due to the invasive nature of these interventions and the likelihood of complications, careful selection of patients for this type of treatment is necessary. Currently, the criteria for selecting patients with a bundle headache for neurostimulation are under development.