foreign [Music] [Applause] [Music] cluster headache introduction recurrent episodes of acute severe right para orbital pain accompanied by autonomic manifestations like ipsilateral meiosis and lacrimation without vision changes are suggestive of cluster headaches pathophysiology the pathogenesis of cluster headache is complex and not completely understood the most widely accepted theory is that primary cluster headache is characterized by hypothalamic activation with secondary activation of the trigeminal autonomic reflex probably via a trigeminal hypothalamic pathway another theory holds that neurogenic inflammation of the walls of the cavernous sinus obliterates venous outflow and thus injures the traversing sympathetic fibers of the intracranial internal carotid artery and its branches clinical features cluster headache is characterized by attacks of severe orbital super orbital or temporal pain accompanied by autonomic phenomena and or Restless or agitation the stereotypical attacks May strike up to eight times a day and are relatively short-lived cluster headache is strictly unilateral and the symptoms remain on the same side of the head during a single cluster attack however the symptoms can switch to the other side during a different cluster attack so-called side shift and approximately 15 percent of cases autonomic symptoms the unilateral autonomic symptoms associated with cluster headache such as peptosis meiosis lacrimation conjunctival injection rhinorrhea and nasal conjunction occur only during the pain attack and are ipsilateral to the pain these symptoms are indicative of both parasympathetic hyperactivity and sympathetic impairment in some patients the signs of sympathetic paralysis meiosis and peptosis persist indefinitely but intensified during attacks sweating and cutaneous blood flow also increase on the painful side particularly in areas of sympathetic deficit circadian periodicity another clinical landmark of the cluster headache syndrome is the Circadian rhythmicity of the relatively short-lived 15 to 180 minutes painful attacks in the episodic form of cluster headache is the most common affecting 80 to 90 percent of patients with cluster headache it's characterized by periods of attacks clusters or bouts in periods of remission and about patients may experience one to eight attacks per day and bouts May last from 7 days to 12 months when not in about patients are usually asymptomatic The Chronic form of cluster headache lacks remissions and is diagnosed after a year without remission or if remission has lasted less than three months chronic clusters may arise to Novo primary chronic cluster headache or evolve from the episodic type secondary chronic cluster headache diagnostic criteria diagnostic criteria for cluster headache according to the international classification of headache disorders Third Edition require all the following at least five attacks attacks characterized by severe or very severe unilateral orbital super orbital and or temporal pain lasting 15 to 180 minutes when untreated during part but less than half of the time course of cluster headache attacks may be less severe and or of shorter or longer duration either or both of the following at least one of the following symptoms or signs ipsilateral to the headache conjunctival injection and or lacrimation nasal conjunction and or rhinorrhea eyelid edema forehead and facial sweating meiosis and or piptosis a sense of restlessness or agitation attacks have a frequency between one every other day and eight per day during part but less than half of the active time course of cluster headache attacks may be less frequent diagnostic criteria for episodic cluster headache require the following attacks fulfilling criteria for cluster headache and occurring in bouts cluster periods at least two cluster periods lasting from seven days to one year when untreated and separated by pain-free remission periods of three months or more diagnostic criteria for chronic cluster headache required the following attacks fulfilling criteria for cluster headache attacks occurring without a remission period or with remissions lasting less than three months for at least one year treatment acute treatments for patients with acute cluster headache clinicians recommend initial treatment with either oxygen or tryptins oxygen should be tried first if available since it's without side effects otherwise subcutaneous sumatriptan six milligram can be used as initial therapy for patients with no contraindications for patients who have a sub-optimal response to inhaled oxygen and are unable to tolerate subcutaneous sumatriptan Alternatives include intranasal sumatriptan or intranasal zomatriptan for patients with acute cluster headache who do not respond to or tolerate oxygen and tryptins Alternatives include intranasal lidocaine oral orgotamine an intravenous dihydro orgotamine note subcutaneous sumatriptan and oxygen inhalation are first-line treatments for an acute cluster headache attack preventive treatments preventive therapy should be started without delay once a cluster episode begins with the goal of suppressing attacks over the expected duration of the cluster period patients with frequent attacks for patients with chronic cluster headache continuous headaches or emission intervals of less than three months and those with episodic cluster headache with relatively long lasting active periods two months or longer the latest guidelines recommend initial preventive therapy with Verapamil rather than glucocorticoids or other agents the onset of benefit is dose dependent the starting dose is usually 240 milligrams daily in three divided doses most patients respond to a total dose of 240 to 480 milligrams daily titration to a total dose of up to 960 milligrams daily may be necessary for some patients to obtain full prophylactic benefit patients with less frequent attacks for patients with episodic cluster headache who have active cluster periods that are infrequent and last less than two months clinicians suggest initial preventive therapy with glucocorticoids alone oral prednisone of 60 to 100 milligrams once a day for at least five days followed by a taper with the dose reduction of 10 milligrams daily is recommended alternative options galconazumab is recommended for patients with prior cluster headache periods lasting longer than one month when first-line preventative medications are ineffective poorly tolerated or contraindicated alternative medications such as lithium to pyrimate and Interventional procedures may be useful for some patients who do not respond to initial preventive Therapies that's all for the video we'll see you next time