How cluster headaches differs from migraine or tension headaches

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Headaches are among the most common of medical complaints. Today we'll be talking about a specific type of headache, called the cluster headache, with Dr. Ioana Medrea. She's an assistant professor of neurology at Upstate and many of the patients she cares for have headaches.

Welcome to "The Informed Patient," Dr. Medrea.

Ioana Medrea, MD: Hi, thank you for inviting me. This is a topic I'm very passionate about, and I'm very happy to discuss this so that people have more awareness of this. Thank you.

Host Amber Smith: Now, headaches are so common. When is it time to make an appointment with a specialist like you?

Ioana Medrea, MD: Yeah, about 80% of people have headaches at some point. The time to see me is when your headaches are interfering with your ability to lead your life.

So what does that mean? How would that look like? A lot of people I see have trouble doing their job because their headache is making them have to miss work or, when they're at work, have to step away and not be as productive as they could be.

Another manifestation would be issues with your ability to do, your jobs at home. So running errands, cleaning the house, maintaining the house. When you're having significant enough headaches that you're finding yourself avoiding those tasks, that's another sign that it may be time to see a headache specialist.

And the last thing is when it's interfering with your social activities. You are shying away from seeing family, friends or participating in things you would normally participate (in) because your headaches are severe enough that you don't want to leave your house.

That would be another sign that you need to see someone for your headaches.

Host Amber Smith: Now, before we get into the details of cluster headaches, can you first help us understand the difference between cluster headaches and a couple of other types of headaches we've heard of: tension headaches and migraines. Are the symptoms the same? Does the headache feel the same for all of those types of headaches?

Ioana Medrea, MD: Generally no. The difference is in severity as well as other characteristics, so the way that we usually think of tension headaches are, they're very common, but they tend to be mild or at most moderate. They generally also occur across the forehead or at the back of the head -- bandlike headaches, and they're your typical headaches that you get when you're a little dehydrated, a little tired, a little stressed, but they're not associated with nausea, vomiting, light or sound sensitivity. And that's where migraines come in, when you have nausea, vomiting, light and sound sensitivity.

Migraines also tend to be more severe than tension-type headaches, and generally they're what brings a patient to medical attention. Now, cluster headaches are different than migraines in that they're probably the most severe headache condition that we treat. They've been estimated to be more severe than active labor or passing kidney stones, so probably one of the most severe conditions that we, in terms of pain, that we encounter in medicine. They tend to be around one eye, specifically. That can happen with migraines. But the telltale sign of this being a cluster headache is that they're briefer than migraines, typically three hours or under, whereas migraines tend to be over four hours.

And then they're also associated with tearing from the eye, redness of the eye, runny nose, congestion of the nose, flushing of the face, and also agitation. Whereas with the migraine, you'd go lay down in bed, with a cluster headache, you might rock, you might find yourself pacing.

And then the last thing that I would say is that with cluster headaches, patients can become so disturbed that they might think of harming themselves, and that also tends to be a characteristic of cluster headaches.

Host Amber Smith: So are all of these headaches you described, are they caused by different things?

Ioana Medrea, MD: The cause of most of these disorders is being investigated, but what we know about tension headaches is they're just a sort of common response to environmental stressors. But in some people who have a propensity for migraine, which tends to be genetic, probably what happens is there's a threshold where the headaches become severe enough that they become migraines.

Now, cluster headaches, the cause is probably very different. There is a genetic link with cluster headaches, and not everyone who has cluster headaches has a family history of it. In fact, most people don't. But it can cluster familiarly in some patients, so there is a genetic link, and we think that a part of the brain, which is also involved in migraine, in a different way, though, the hypothalamus, probably is a trigger for cluster headaches.

So, they're not all caused by the same thing. They're all caused probably by different genetic factors. And migraines have, again, different genetic links than cluster headaches and also tend to occur in families.

So, all of them have somewhat different causes.

Host Amber Smith: Now, when you see a first-time patient complaining about a headache, how do you determine which type it is?

Ioana Medrea, MD: The most important part, as in most of neurology, is listening to the patient describe their symptoms. So, where is the headache occurring? How long is it lasting? Does it have other associated features, such as nausea, vomiting, light/sound sensitivity, for migraine? Is it associated with tearing and the other autonomic symptoms, which is the runny nose, tearing, facial flushing, the agitation that we talked about. And then, the duration of the headache would be another clue.

That is sort of the way we diagnose these headaches. It's generally a clinical diagnosis.

Host Amber Smith: So you rely on the patient's history, the story that they tell you about how they've experienced it.

Ioana Medrea, MD: Yes.

Host Amber Smith: I'd like to learn more about cluster headaches in general. how do your patients describe their cluster headaches when they come to see you?

Ioana Medrea, MD: Everyone who comes with cluster headaches generally has a very pronounced sort of pain with their headache. Some of them describe it as a searing pain in the eye. Some have said that it's like a hot poker. Some have said that it's a knife trying to poke out their eye. And generally it's very, very severe pain. And the adjectives used to describe it are generally that.

The other thing that they described are also, you know, the autonomic features, which we listed, and also a lot of agitation with the headache.

Host Amber Smith: Do you see anything specific in your patient population, or do cluster headaches affect people of all ages and genders?

Ioana Medrea, MD: They do affect people of all ages and genders generally, but the gender predisposition is such that there are more men than women, somewhere of a factor of 3 to 1. And then it tends to be more in middle ages. So for men it's 30 to 50, and then women maybe a little bit later, when these headaches are occurring.

And the last thing would be that there's an association with smoking. So smokers are far more likely to have cluster headache than nonsmokers, and about 70% of patients with cluster headache are smokers.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Ioana Medrea. She's an assistant professor of neurology, and we're talking about cluster headaches.

Are there theories about what causes cluster headaches?

Ioana Medrea, MD: We know that a part of the brain, the hypothalamus, is involved in cluster headaches, and we know that there is a periodicity (occurrence at regular intervals) to most patients with cluster headaches, and they tend to happen with a seasonal sort of preponderance.

Commonly, the seasons that they occur in are spring and fall, but sometimes the people have also a summer sort of seasonal prevalence of the headaches. We think that there is a sort of mechanism that turns on in the hypothalamus, which has to do with the seasonal preponderance of cluster headaches. And when it turns on, it starts causing headaches from the hypothalamus, and we have found some genetic risk factors for this, and we think that that might be a part of it.

Another consideration would be if this is something that comes on with other illnesses or masses, rarely, which are in the area of the hypothalamus or very rarely in the brain stem.

Host Amber Smith: So, genetics may play a role in this. Is there anything else that might make a person more susceptible to cluster headaches?

Ioana Medrea, MD: So, as I mentioned earlier, also smoking. That is one of the big associations that we see, and, in fact, we discuss often: If patients stop smoking, their cluster headaches might improve.

Host Amber Smith: Are cluster headaches considered a chronic problem, or is this something that you have the ability to cure?

Ioana Medrea, MD: Unfortunately, we don't have a cure for cluster headaches. They are chronic in that they tend to continue for a long period of time, but they're not continuous in most people. In most people, they're episodic, and they tend to last between four to 10 weeks, and they tend to happen seasonally, as I had mentioned.

Rarely, about 10% to 20%, of cluster headache patients do become chronic cluster headache, which means that they're having them continuously with no break in between the periods of cluster headaches. But that's not most patients. In most patients, it tends to be an episodic pattern.

Host Amber Smith: Well, let's talk about treatment strategies. Once you diagnose someone with a cluster headache, do you first have to rule out something like a brain tumor or aneurysm?

Ioana Medrea, MD: Yeah, so we will always order an MRI of the brain to ensure that there isn't a mass, in either the hypothalamic area or the brain stem area. And, once we do that, we can proceed to treatment. In fact, I often will start with treatment even before the MRI is done because they're such painful conditions that I don't want my patients not to be treated.

The way that we treat is a multi, sort of, dimensional approach. So we have acute treatments, which is for attacks as you're having them, transitional treatments to immediately decrease the frequency of your attacks and longer-term treatments that take a few weeks to kick in but take over from the transitional treatments.

So, in terms of acute treatments, we'll use triptans, which are also used in migraines. But we want to have triptans such as sumatriptan injectable or nasal spray, or zolmitriptan injectable. The reason why is because these triptans are very fast onset, usually 15 to 30 minutes, and so the headache relief is much quicker than taking them by mouth. The next treatment that we use is oxygen. And usually we want this at high flow, preferably over 12 liters per minute and up to 15 liters per minute. There's a lot of evidence that this works as well as triptan and this we will use in conjunction.

Host Amber Smith: So you talked about oxygen and the medication, the triptans. Do those stop the headache, or are they providing pain relief? How do those work?

Ioana Medrea, MD: Those provide pain relief, and that's the first sort of thing we do. And then the transitional treatments are either steroids by mouth or steroids by injection. The injection is in the occipital area at the back of the head and usually do high dose steroids for that, preferable by-mouth steroids just because you have less systemic exposure to steroids if you do just an inch at the back of the head, so you tend to have less side effects, and that's a transitional treatment, but it only lasts a few weeks, and then the headaches would come back.

So, because of that, we also do a long-term treatment. Typically it's either verapamil, which is usually a blood pressure pill but has been shown in trials to work very well for this specific condition to stop the headaches from occuring, or the other thing we might do is Emgality, or galcanezumab, which is a new medication which you inject once a month. Both of them work very well at stopping the headaches from occurring but take some time to have an effect.

So, because of that, we have the transitional treatment with steroids, either by mouth or by injection at the back of the head.

So, generally, that is our approach to care, and as I said, it's multipronged, with the acute treatments for when you have a headache, the transitional treatments in the short term and the longer-term treatments.

Once someone has been outside of a cluster cycle for about a month, we start tapering them off of the longer- term medications so that we have those medications to use at a next cycle.

Host Amber Smith: I'd like to ask you about the steroid injections. Is that something that is done in the hospital or can you do that in the office?

Ioana Medrea, MD: So, I do that in the office and, I will make sure that I get my patients in within a day, once I know that they're in cycle, so we can do that. And generally it works very well. Within about 72 hours, most patients have a resolution of their headaches.

Host Amber Smith: Are there any lifestyle modifications that can help?

Ioana Medrea, MD: So, the most common thing that I always talk to my patients about is smoking cessation. As I mentioned, a lot of these patients are smokers, and there's been studies showing that this is very helpful if you stop smoking. And that is the most common thing. Additionally, we do talk about stress reduction, and we talk about ways to accomplish that, but generally with cluster headaches, that has less of an effect than in something like migraines.

So, the main one would be smoking cessation.

Host Amber Smith: Are there any foods or vitamins or supplements to add or to avoid if you have cluster headaches?

Ioana Medrea, MD: There hasn't been any sort of work done on a lot of supplements. There is a trial going on about starting vitamin D and whether this helps or not with cluster headaches, but we don't have data from that yet.

What I would say is that we know that nitroglycerin can provoke cluster headaches, so there has been maybe some recommendation on avoiding processed meats because sometimes they have nitro added to it. And then nitroglycerin patches that are used in cardiac disease can sometimes bring on episodes in people.

So those are things to consider.

Host Amber Smith: Does having cluster headaches put a person at higher risk for stroke or anything else?

Ioana Medrea, MD: So there hasn't been any data that I'm familiar with about that specifically. If I had to warrant just an educated guess, I would say probably not, since there's no cardiovascular mechanism for cluster headaches.

Host Amber Smith: For someone with known cluster headaches, are there any red flags that signal that they need to seek emergency care?

Ioana Medrea, MD: Yes, I'd say if they have any new neurological symptoms, that would always be worrisome. So those would include loss of vision, missing chunks of vision with dark spots, double vision, problems with speech becoming garbled or nonsensical, problems with numbness or tingling affecting a part of the body that's prolonged, problems with weakness affecting a part of the body that's prolonged, and problems with ambulation (walking or moving around), so any new neurological symptom would be concerning.

Host Amber Smith: I appreciate you making time for this interview. Thank you.

Ioana Medrea, MD: Thank you for your time.

Host Amber Smith: My guest has been Dr. Ioana Medrea. She's an assistant professor of neurology at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.