Migraine and cluster headache is classified as vascular headaches because they are thought to originate from the blood vessels in the head. They are both severe one-sided headaches, often associated with nausea, photophobia (dislike of light) and sensitivity to loud sound.
A migraine starts gradually and builds up over an hour or so as a throbbing pain in one temple. When migraines are preceded by visual or other disturbance, known as an aura, it is called classical migraine, while those that occur without warning are called common migraine; at times this aura may occur without being followed by a headache. Migraine may also be associated with tingling on one side of the body and other disturbances such as difficulty in concentrating or finding words. Occasionally a migraine may mimic a stroke, with weakness or paralysis of one side of the body, which recovers with the headache, called hemiplegic migraine. Migraines last from 4 -48 hours, and may be followed by a ‘hangover’ with symptoms such as mental dullness or sleepiness lasting a few hours. In children, migraine may manifest as recurring abdominal pain (tummy ache).
Cluster headaches start suddenly, usually at the same time of day or night, often 2-3 hours after falling asleep. It is an extremely severe pain usually radiating from neck to temple, and is associated with a blocked nose and /or tearing of the eye on the side of the pain. There may also be drooping of the eyelid (Horner’s syndrome) or swelling and redness of the same side of the face. The pain can be so severe that these headaches have been nicknamed ‘suicide headache’. Unlike migraine, in which the sufferer wants to lie still, the cluster headache sufferer normally has to move around to obtain some relief from the pain. The headache may also be preceded by other symptoms such as strange taste or smells. Clusters last from one to 4 hours and may either occur several times a day followed by a period of freedom, known as an episodic cluster or occur continuously, known as a chronic cluster. Clusters are also often followed by a hangover with a feeling of mental ‘fog’ or dullness.
Migraine affects some 10% of the population, and is more common in women, usually beginning between ages 10 and 40 and often runs in families. Cluster headaches are less common and affect more men, usually starting between teens and middle age. There may be a slight familial tendency but a stronger association with other family members having a migraine.
Both headaches are due to dilation of blood vessels around the brain affecting the trigeminal nerve that supplies sensation to the face. Cluster headache is thought to be due to an abnormality in the hypothalamus, the part of the brain that responds to changes in day length, season etc, and is called a neurovascular headache. Neither kind of headache is a symptom of a brain tumour or other serious problem, but the first episode should be evaluated by a health practitioner to ensure the correct diagnosis.
There are many triggers for both migraines and cluster headache including changes in daily habits such as mealtimes, sleep patterns, physical or emotional stress [many migraines occur at the beginning of a holiday], and even unaccustomed exercise. Environmental factors can also have an effect, such as bright or flashing lights, loud noises, smells or perfumes, exposure to smoke and alcohol – cigarette smoking and alcohol are potent triggers for cluster headache, although when not in a cluster cycle, alcohol may be enjoyed without any problem. Migraine can also be associated with changes in hormone levels during a woman’s menstrual cycle or with use of the oral contraceptive pill.
Other less common causes include allergic reactions, including food allergy, for example, non-celiac gluten sensitivity, certain foods and preservatives, especially smoked, fermented, pickled, or marinated foods which contain tyramine, monosodium glutamate (MSG) or nitrates. These include red wine, aged cheese, chicken livers, figs, certain beans, and smoked or cured meat and fish. Unfortunately chocolate and caffeine can also cause migraines, as can even fruit such as avocado, banana, citrus, nuts, onions, and peanut butter.
Cluster headaches are also triggered by change of weather or altitude.
If you feel that there may be unknown factors causing your headaches, it may help to keep a diary for a month or so. This headache diary should record when and where your headaches occur, how severe they are, what you’ve eaten and drunk in the last 24 hours, how much sleep you had, and any other symptoms as well as other factors such as where a woman is in her menstrual cycle.
HOW DO WE TREAT THESE HEADACHES?
The usual treatment of these headaches falls into 2 groups: those that treat the pain, and those that prevent the headache.
The pain of migraine may respond to aspirin if taken early in the attack, sometimes combined with anti-nausea medicine if needed. Migraines also often respond to nonsteroidal anti-inflammatories (NSAID), either by mouth, suppository or injection.
Ergot preparations such as Cafergot and Migril are specific to these headaches as they act on the blood vessels, and another group, the Triptans are very effective with fewer side effects and can be used by mouth or by injection. All of these medicines contract blood vessels, are very dangerous in overdose and must be used with caution in people with cardiovascular disease.
Surgery to the vessels around the skull has been advocated as a treatment for migraine, but the benefits are so far uncertain.
Cluster headache does not respond to simple analgesics and once established little help, although breathing 100% oxygen usually gives some relief. Triptans can work if taken early in an attack, and Lignocaine nasal spray is sometimes effective but may have long term effects on the nasal mucosa [the lining inside the nose].
A course of oral prednisone may help stop a cluster, as may injection of steroid into the occipital nerve by an experienced practitioner.
Preventive treatments for both kinds of headache include Beta blockers, antiepileptic medications such as Topiramate and Valproic acid, NSAIDs, Tricyclic antidepressants such as Amitriptyline, high doses of calcium channel blockers such as Verapamil, and Cyproheptadine, an antihistamine. For cluster headaches, small doses of lithium have been shown to help. Older remedies such as Methysergide and phenelzine are rarely used nowadays due to side effects.
In severe intractable cases, surgery to the trigeminal nerve may be recommended, but this has drawbacks such as anaesthesia (lack of sensation) of the cornea of the eye. Injection of glycerol into the nerve is a promising alternative, with less danger to the eye.
Other treatments include avoiding drastic changes in blood sugar levels by eating regularly and eating a low Glycemic Index diet, which means avoiding all sugars and refined flours.
- Niacin [Vitamin B3] 500mg has been shown by research to be both a useful preventive and treatment for migraine. This does cause flushing as well as other side effects, and such high doses should only be taken under medical supervision.
- Riboflavin [Vitamin B2]400mg daily has been shown to be effective for prevention and has minimal side effects. The effect begins to show after a month and is maximal after 3 months.
- Feverfew 250mg/day helps prevent migraine.
- Petasites Hybridus [Butterbur] has been shown to be an effective preventive for migraine when taken as a dose of 75mg standard extract daily or 50mg twice daily.
- Omega- 3 oils are naturally anti-inflammatory.
- Magnesium 300mg and calcium 600mg daily will treat or prevent migraine in some people. Magnesium as glycinate will cause less diarrhoea as a side effect than other forms.
- Chiropractic realignment of the spine may help.
- Acupuncture is very effective both as treatment and prevention for both kinds of headache.
- Stress relief in the form of massage and relaxation techniques.
- Ginger tea is helpful for nausea.
- 5-hydroxytryptophan (5-HTP), 400 – 600 mg per day.
- Coenzyme Q10 100mg tds and alpha lipoic acid have also been used with effect in some with migraine.
- Nat Mur, Kali Phos and Headache Combin are homoeopathic remedies.
- For cluster headache, melatonin 9mg at night is recommended This is a high dose and should only be used under medical supervision.
- It is thought that cluster headache sufferers may have high serum copper levels; these can be reduced by zinc supplementation.
- Exercising vigorously may abort a cluster attack.
- During a cluster, drink large amounts of water e.g. 250ml every 30mins, apply hot or cold packs to the head, and drinking coffee may help, but coffee can also be a trigger for some.
- Eating peri peri sauce and holding it under the tongue can help.
WHEN TO WORRY
Neither headache has long term consequences, but both can be disabling, and current research suggests that frequent migraine may increase the likelihood of stroke. It is therefore important to control these headaches as they can interfere with normal functioning.
Any headache that is worse than usual or has features that are not normally part of your pattern should be seen by your Doctor.