WBR1078

Author	PageAuthor::Chetan Lokhande
Exam Type	ExamType::USMLE Step 3
Main Category
Sub Category	SubCategory::Head and Neck, SubCategory::Neurology
Prompt	[[Prompt::A 34-year-old man who works as a manager in a big pharmaceutical company comes to your office with a headache since 3 days. On enquiry the headache appears to be only on the right side. He also reports of having some tearing, redness and rhinorrhea. Patient claims he had a similar episode 3 months back where the doctor gave him Sumatriptan and oxygen via nasal cannula, which subsided the pain. The patient also says that he has 5 large cups of coffee everyday. What measures should be taken to prevent this headache?]]
Answer A	AnswerA::Propranolol
Answer A Explanation	AnswerAExp::Proranolol is used for the prophylaxis of migraine and not cluster headache.
Answer B	AnswerB::Verapamil
Answer B Explanation	AnswerBExp::Verapamil can prevent the attacks of cluster headache. It is widely used to prevent headaches .
Answer C	AnswerC::Home nasal oxygen
Answer C Explanation	AnswerCExp::100% nasal oxygen is the treatment of choice to abort an acute attack. It may be used alone or in conjunction with Sumatriptan to treat cluster headache.
Answer D	AnswerD::Cut down his coffee intake
Answer D Explanation	AnswerDExp::Cutting down coffee slowly may prevent a headache that usually occurs due to caffeine withdrawal. However it has not effect on cluster headache.
Answer E	AnswerE::Bright light therapy
Answer E Explanation	AnswerEExp::Bright light (including sunlight) may trigger cluster attacks . Hence , it may not be used as a measure to prevent cluster headache.
Right Answer	RightAnswer::B
Explanation	[[Explanation::Cluster headaches are recurring bouts of excruciating unilateral headache attacks of extreme intensity. The duration of a typical CH attack ranges from about 15 to 180 minutes. Most untreated attacks (about 75%) last less than 60 minutes. The onset of an attack is rapid and most often without preliminary signs that are characteristic in migraine. Preliminary sensations of pain in the general area of attack, referred to as "shadows", may signal an imminent CH, or these symptoms may linger after an attack has passed, or even between attacks. Though a CH is strictly unilateral, there are some documented cases of "side-shift" between cluster periods, extremely rare, simultaneously (within the same cluster period) bilateral headache. The pain occurs on one side only (unilateral), around the eye (orbital), particularly above the eye (supraorbital), in the temple (temporal), in any combination. The pain of CH is remarkably greater than in other headache conditions, including severe migraine. The term "headache" does not adequately convey the severity of the condition; the disease may be the most painful condition known to medical science. The pain is described as stabbing, burning or squeezing and may be located near or behind the eye and at the back of the head or neck. Prevention: Preventive treatments are used to reduce or elimination cluster headache attacks; they are generally used in combination with abortive and transitional techniques. 1.Verapamil The recommended first-line preventative therapy is verapamil, a calcium channel blocker. Verapamil was previously underused in people with cluster headache. Steroids There is little evidence to support a long-term benefit from steroids, but they may be used until other medications take effect as they appear to be effective at three days. They are generally discontinued after 8–10 days of treatment. 2.Surgery Nerve simulators may be an option in the small number of people who do not improve with medications. Two procedures, deep brain stimulation or occipital nerve stimulation, may be useful; early experience shows a benefit in about 60% of cases. It typically takes weeks or months for this benefit to appear. A non-invasive method using transcutaneous electrical nerve stimulation (TENS) is being studied. A number of surgical procedures, such as a rhizotomy or microvascular decompression, may also be considered, but evidence to support them is limited and there are cases of people ending up worse off. 3.Other Lithium, methysergide, and topiramate are recommended alternative treatments, although there is little evidence supporting the use of topiramate or methysergide. This is also true for melatonin and ergotamine. Valproate, sumatriptan and oxygen are not recommended as preventative measures. Botox injection have shown mixed success. Management: Treatment for cluster headache is divided into three primary categories: abortive, transitional, and preventative. There are two primary treatments for acute CH: oxygen and triptans, but they are underused due to misdiagnosis of the syndrome. During bouts of headaches, triggers such as alcohol, nitroglycerine and naps during the day should be avoided. 1.Oxygen Oxygen therapy may help people with CH, but it does not help prevent future episodes. Typically it is given via a non-rebreather mask at 12-15 liters per minute for 15–20 minutes. Around 70% improve within 15 minutes. It is unclear if hyperbaric oxygen therapy is better than high flow oxygen. 2.Triptans The other primarily recommended treatment of acute attacks is subcutaneous or intranasal sumatriptan. Sumatriptan and zolmitriptan have both been shown to improve symptoms during an attack with sumatriptan being superior. Because of the vasoconstrictive action of triptans, they are contraindicated in people with ischemic heart disease. 3.Opioids The use of opioid medication in management of CH is not recommended; they may make headache syndromes worse and their long-term use is associated with dependency, addiction and withdrawal syndromes. Prescription of opioid medication may additionally lead to a delay in diagnosis, undertreatment, and mismanagement. Other The vasoconstricting ergot compounds may be useful, but have not been well studied in acute attacks. Educational Objective: Since the patient has unilateral headache with tearing, redness and rhinorrhoea the diagnosis is 100% cluster headache. The treatment for an acute attack is Sumatriptan and oxygen via nasal cannula . However, cluster headache is prevented by using calcium channel blockers like verapamil, cyproheptadine, topiramate, valproate, lithium carbonate and amitriptyline . References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::CLuster headache, WBRKeyword::Migraine
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::