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M a r c h 2 0 0 5 • w w w. c l i n i c a l n e u r o l o g y n e w s .

c o m Pain and Headache 29

Prophylaxis a Must for Cluster Headache Patients

Transitional treatments must kick in quickly; nism of action may involve decreasing af- 3,000 mg at bedtime, is sometimes effec-
ferent impulses to the spinal trigeminal tive.
corticosteroids are the therapy most commonly used. nuclear complex. Some small, uncontrolled studies sug-
For long-term prevention, a number of gest that topiramate may be effective for
BY ROBERT FINN tenance preventives are tapered up to a drugs work well, but many patients will preventing clusters.
San Francisco Bureau therapeutic dose. The transitional drug need to be on combination therapy, taking When trying topiramate, increase the
and maintenance preventive drug are typ- two, three, or even four drugs to fully pre- dosage in 25-mg increments every 4-5 days
L A S V E G A S — Every cluster headache ically started at the same time, Dr. Rozen vent recurrences. until the patient is taking 75-100 mg/day.
patient needs to be on a prophylactic drug, said. “Melatonin is really my first-line choice When patients do respond to topiramate,
Todd D. Rozen, M.D., said at a symposium Corticosteroids are the most common- because it is easy to get over the counter it’s usually in a short period, 1-2 weeks af-
sponsored by the American Headache So- ly used transitional treatment. Start pred- and there are no side effects,” Dr. Rozen ter starting the agent, he said.
ciety. nisone at a dosage of 60-80 mg/day, ta- said. “[For] a small percentage of cluster Other preventive treatments that may
“I tell them, ‘I’m not happy, and you pering down over a period of 10-12 days, patients, the night I give them melatonin be effective are transdermal clonidine, ti-
shouldn’t be happy, until you’re cluster he said. is the last time they’re going to have a clus- zanidine, indomethacin, nasal capsaicin,
free on prevention,’ ” said Dr. Rozen of the Naratriptan can be used at a dosage of ter.” The typical dosage is 9 mg at bed- gabapentin, baclofen, and histamine de-
Michigan Head-Pain and Neurological In- 2.5 mg b.i.d., but monitor the patient for time, although some patients have re- sensitization.
stitute, Ann Arbor. rebound headaches. Ergotamine, at a quired higher doses. For some patients, steroids seem to be
There are two types of prophylaxis for dosage of 2 mg at bedtime or b.i.d., also Verapamil is the best cluster preventive the only thing that works, Dr. Rozen not-
cluster headache: transitional treatments, appears useful. currently available, Dr. Rozen said. He rec- ed, and of course patients shouldn’t take
which are intended to prevent cluster Dihydroergotamine can be given by dai- ommended tapering the dosage up quick- corticosteroids chronically.
headaches from occurring for a short pe- ly intramuscular injections for 1-2 weeks, ly, since some patients will need up to 1 He reported that he has had success in
riod of time (typically 7-14 days), and or by an intravenous infusion for 3 days. g/day. ECGs must be performed at every a single patient with mycophenolate
maintenance preventive treatments, which For reasons that are unclear, greater oc- dosage above 480 mg to monitor for heart mofetil (CellCept), the steroid-sparing im-
are designed to keep a patient cluster free cipital nerve blocks seem to work well, block. munosuppressant.
while in a cluster cycle. giving some patients up to 13 days free of Lithium carbonate, 300 mg t.i.d., ap- Dr. Rozen acknowledged being a mem-
Transitional treatments must kick in cluster headaches, even when their pain pears to be well tolerated in cluster ber of the advisory board of Ortho-Mc-
quickly. They’re used for 10-14 days, after (like that of most cluster patients) is not headache. Neil Pharmaceuticals Inc., whose products
which they’re tapered down as the main- located in the occipital area. The mecha- Valproic acid, pushed up to a dosage of include topiramate (Topamax). ■

History, Physical Critical in Comorbid Conditions Can Guide Migraine Prophylaxis

Secondary Headache Work-Up Drug
Side Relative
Efficacy* Effects** Contraindications
L A S V E G A S — Even in a neu- evidence of central nervous sys- Liver disease, Mania, epilepsy,
rologist’s office, every headache tem involvement, either in the Divalproex 4+ 2+ bleeding disorders anxiety disorders
patient merits a general history brain or its coverings. If there’s Epilepsy, possibly
and a physical examination, any indication of CNS involve- Gabapentin 2+ 2+ mania
which may be the best tools with ment, the next step includes neu- Epilepsy, obesity,
which to differentiate secondary roimaging and possibly examina- Topiramate 4+ 2+ Kidney stones possibly mania
from primary headaches, John tion of the patient’s cerebrospinal
G. Edmeads, M.D., said at a sym- fluid. Antidepressants
Depression, other
posium sponsored by the Amer- 씰 If there are no signs or symp-
pain disorders,
ican Headache Society. toms of CNS involvement, then
Tricyclic Mania, urinary anxiety disorders,
“The headache never walks conduct a general medical antidepressants 4+ 2+ retention, heart block insomnia
alone” when it is secondary to a screen. This should include a
general medical condition, said CBC; an erythrocyte sedimenta- Selective Depression,
serotonin obsessive-compulsive
Dr. Edmeads of Sunnybrook tion rate; electrolytes, including
reuptake inhibitors 2+ 1+ Mania disorder
Medical Centre, Toronto. calcium and phosphate; BUN and
“There’s always something on creatinine; liver enzymes and Monoamine
history or physical to give you a bilirubin; thyroid function stud- oxidase inhibitors 3+ 4+ Unreliable patient Refractory depression
clue that there’s a general med- ies, including TSH, T3, and T4; β-Blockers
ical disease going on. And once and a chest x-ray. Answers will Asthma, depression, Hypertension,
you have this clue you can diag- come back within a day or two 4+ 2+ heart failure, angina
nose them through a focused and will cost less than a couple of Raynaud’s disease,
work-up that won’t cost an arm hundred dollars, Dr. Edmeads diabetes
and a leg,” he said. said. Calcium Channel Blockers
Dr. Edmeads offered the fol- 씰 If those studies are negative, Migraine with aura,
lowing suggestions: consider serum protein elec- Constipation, hypertension,
씰 Neurologists can’t assume that trophoresis and arterial blood Verapamil 2+ 1+ hypotension angina, asthma
patients have had a thorough gases. In winter, consider carbon NSAIDs
evaluation before reaching their monoxide poisoning and test for Ulcer disease, arthritis,
offices. Dr. Edmeads said that he carboxyhemoglobin. Carbon Naproxen 2+ 2+ gastritis other pain disorders
has had patients ask about the monoxide poisoning often results
blood pressure cuff as if they had from poorly maintained heaters
Riboflavin 2+ 1+ Preference
never seen one before. and will often present as daily, dif-
CoQ10 2+ 1+ for
씰 Be suspicious if the patient’s fuse, nocturnal headaches that Feverfew 2+ 2+ natural
signs and symptoms don’t clear- clear up in the morning when pa- Botox 2+ 1+ products
ly meet International Headache tients get out into the fresh air.
Society criteria for primary 씰 If all results are still negative, *efficacy scale: 1+ = low, 4+ = high.
headache. Any patient whose but you still have a strong suspi- **side effects scale: 1+ = mild, 4+ = serious.
headache doesn’t meet the soci- cion that the headache is the re-
Source: Stephen D. Silberstein, M.D., speaking at a symposium sponsored by the American Headache Society
ety’s criteria deserves additional sult of a general medical condi- in Las Vegas, who acknowledged financial relationships with a large number of pharmaceutical companies with
investigation. tion, consider a consultation with products for migraine
씰 If it’s not clearly migraine or a general internist.
tension-type headache, look for —Robert Finn