This is what I found

Mark.


                                The Chronic Cluster Headache and the Bipolar Spectrum

The cluster headache is a unique form of migraine. It occurs predominantly, almost exclusively, in young or middle-aged males. It is characterized by intense pain in one eye (rarely, both), associated with swelling and redness in that eye and congestion and discharge on the nose on the same side. These symptoms are suggestive of sinus infection and, for that reason, cluster headache is often misdiagnosed as sinusitis.

The cluster headache has remarkable periodicity. It is of shorter duration than most forms of migraine, lasting an hour or an hour and a half at the most. It often recurs several times a day (a behavior highly unlikely in sinusitis). It has a remarkable predilection for appearing at night, often awakening the victim with intense pain at the same hour or hours every night.

Another curious feature of its periodicity, and the origin of its name, is its predilection to appear in clusters, often many times daily for a duration of a month or so, and then go away. It sometimes has a seasonal incidence and, in my experience at least, appears most commonly in the spring and the fall — thus another reason fo suspecting, erroneously, sinus disease.

We have rather good treatments for the disorder, although some patients are indeed treatment-resistant. The triptans, those same drugs which are effective in the treatment of conventional migraine, can be helpful, and cluster can also be prevented by the administration of some of the anticonvulsants such as Depakote or Topamax or even by the administration of Lithium.

I now want to talk about a peculiar and uncommon feature of the cluster headache, and that is, in some people it simply doesn’t ever go away. It continues, not for a few weeks, but for months or years.It is one of the most treatment-resistant (perhaps until now) forms of chronic pain there is. I now want to explore why the chronic cluster happens and what to do about it.



James came to me when he was 37 years old. His first cluster appeared at quite a young age, 17 years. At first his sieges were seasonal, but within the span of but a few years they became incessant, and for the last 15 years of his life he had at the most gone one month without a headache. Most of the rest of the time he suffered 3 or 4 headaches daily, usually at night. He described an unusual feature, that his headaches would always begin in one eye, but as they terminated they would shift briefly to the other eye (I’m not sure I have ever heard that description before). He has consulted many  excellent physicians and his treatment was clearly well thought out. Among the drugs he received were Verapamil, Lithium, Depakote, Neurontin, Buspar, and Sansert, all appropriate for the treatment of cluster, but none worked. Various injections about the head and neck were unhelpful also, and when he came to me, he was receivng Duragesic, a very strong opiate, in the form of a skin patch, and Hydrocodone up to 4 times daily. He was quite unable to work and on disability, but he said on this program there were interludes when his life was tolerable — but more often not.

I searched his past history, as I always do, for clues to bipolarity — and indeed they were there. He described lifelong sleeplessness, mind racing and occasional intervals of high energy hyperactivity. I learned also that he was in counseling regarding issues of anger and impulse control, certainly common features in the bipolar. However, in the course of his treatment for migraine he had received many drugs which are effective mood stabilizers in the bipolar. Verapamil, Lithium, Depakote and Neurontin can all be helpful in this regard, but they had not been in James.

I had few treatment choices. My patient had already been on most of the drugs we use for the treatment of both cluster  headache and bipolar disease, without success. I did for a while reinstitute Lithium in combination with Lorazepam (Ativan), and on this program he had a few good months, but then the headaches recurred full force, and his ongoing problems with mind racing, sleeplessness, impulse and unprovoked anger continued. Some 3 years into his treatment I made an inquiry that I have only recently learned is an extremely important question for the painful. I asked him if he was subject to vivid dreams, and he told me that indeed he was. They were frequent, frightful and were attended many times by a sense of paralysis on awakening. He also responded to my question that he did indeed suffer attacks of daytime sleepiness and periodic intervals where he would lose muscular control. On these occasions his knees would buckle under him, occasionally causing him to fall, and on other occasions he would suddenly and inexplicably drop things that he was holding in his hand. In but a few moments I had learned, after 3 years of failing to ask the appropriate questions, that my patient suffered the full expression of narcolepsy, an important segment of the bipolar spectrum. I found a window of opportunity and I elected to treat his narcolepsy with the stimulant Ritalin, hoping that treatment of the underlying (and heretofor hidden) neuropsychiatric illness would relieve my patient’s pain.

Within but 2 weeks he called to report that he was experiencing marvelous benefit from the Ritalin. Not only had his headaches lessened in frequency and severity, his daytime sleep attacks had diminished, as had his cataplexy (falling and dropping things). His dreams were much less intense and he reported that his mood was much better. Remarkably, he told me he felt much less angry and driven. He was quite pleased with his progress, as was I.

I have written in previous blogs about the potential role of stimulant therapy in the bipolar, particularly the painful bipolar. I do not suggest that Ritalin therapy is appropriate for all patients with cluster headache, but I do suggest that it is appropriate in those who suffer bipolar disease.

I will admit it is counterintuitive to use a stimulant for the treatment of cluster headache. One would expect such a drug would make the cluster worse. In James, however, it didn’t. And I am increasingly learning that the counterintuitive approach to therapy may be the correct one.

Before leaving the subject of bipolar disease, narcolepsy, and chronic cluster headache, I want to remind you of the complexity and expanse of this disorder. Please go to my blog entitled “Narcolepsy, Phobia, and Pain” in which I describe a young woman who was experiencing progressively severe migraine headaches and an increase in her “anxiety level.” As I had in James, I inquired about her dream life, and she clearly also suffered narcolepsy. I elected to treat her, counterintuitively and unconventionally, with Ritalin, and it worked remarkably well. Not only did it diminish her anxiety and relieve her headaches, it quite unexpectedly cured her longstanding dentist phobia, a problem so great that she was unable to submit herself to dental care without premedication with a sedative. After starting Ritalin, her anxiety about the dentist so diminished that she no longer required sedation. So, you see, we’ve tossed phobia into the biolar/narcolepsy/migraine complex.

There where several anecdotal reports about success with Ritalin. In my experience, it does prevent hits and shadows for a few hours once you take it, but then you may experience a rebound a rebound attack.