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This page was online as an interactive page for about a year to give you
the opportunity to ask Doc Greg (a physician who sufferers from cluster headaches)
technical questions about cluster headaches, it's traits, symptoms, and some of it's
treatments. Below are the most asked questions...
All of the information contained in
these documents is intended for the education of those suffering from cluster headaches so
that they may better understand their disease. It is not intended for self diagnosis, self
management, or self medication. Use of this material is at the readers own risk. Consult
your doctor before making any changes in your medical care.
Why do cluster headache sufferers bang their heads?
Do cluster headaches run in the family?
OXYGEN: It’s use, why it works, and why it can hurt
Imitrex, Zomig, Maxalt, Amerge and Cluster Headaches
Verapamil (Calcium Channel Blockers) and Cluster Headaches
Why do clusterheads bang their heads?
One of the things that tends to distinguish cluster headaches from other head pains, is
that many of the sufferers bang their heads in order to relieve the pain. It seems odd to
others, many feel that the sufferer is going to hurt him/herself while doing
this…though this is rarely the case. The sufferer is banging because it feels
better…not because they are looking for more pain.
So why does it feel better? There are, of course, several theories to explain this. The
one that I am fond of, however, is that of the "Gate control theory".
The human body has set up it’s sensory nerves such that stimulation
of nerve #1 will cause a decrease in its neighbor, nerve #2’s, activity. This helps
the body locate exactly where the stimulus is coming from. The point of maximal
stimulation (#1) is pronounced, while #2 is suppressed to keep the body from becoming
confused with too many inputs.
For example, scratching around a mosquito bite can actually make the itching of the bite
subside a bit. Most people have done this at one time or another.
So, stimulating the nerves in the head by banging, ice, or whatever, the pain receptors
that are firing off due to the headache are temporarily suppressed. A sufferer does not
bang his head to cause more pain…rather it is to suppress the horrible. Two pain
receptors firing at 50% pain feels better than the one firing at 100%.
And that, I believe, is why clusterheads bang.
As a note, if interested, the gate control theory explains why insects fly into lights.
The receptors in their eyes work in a similar manor. The brightly stimulated receptors due
to the light suppress the neighboring receptors. Therefore, the world just next to the
light appears to be the darkest (those receptors are suppressed from the light). Insects
fly to the darkest area they can…which is just at the edge of the light.
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Do cluster headaches run in the family?
No, generally they do not. There are some cases where more than one family
member may have clusters, but this is unusual. Often, there will be some family history
of migraines, but clusters do not seem to be genetically passed.
If you have clusters it is doubtful that your children will.
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OXYGEN: It’s use, why it works, and why
it can hurt
One of the features of cluster headaches, is that it is often very
responsive to oxygen. The response can be only temporary, and not work at all in some
people, but for many, it is a quick and painless way to treat acute attacks.
Oxygen is a medication controlled by the FDA. To get it, you need a prescription. There
are people who work around this by getting oxygen intended for non-human consumption (i.e.
welding, etc), but the users run the risk of it not being pure. The same restrictions are
not present when making industry grade oxygen when compared to medical grade. Toxins, oil,
etc, are not as closely monitored, and may be present. Beware.
Most people require high concentrations of oxygen to benefit them significantly. This is
obtained at 8+ liters per minute flow through a mask. Relief is usually seen within a few
minutes, but may only be partial. Removing the oxygen will often cause the headache to
return.
Why does it work? Well, remember that cluster headaches are considered a vascular headache
(actually much more involved than just vascular, but there is a definite vascular
component to it). Many of the medications that relieve CHs cause constriction of the
vessels in the brains (Ergotomines, Imitrex, etc), and oxygen is no different. The brain
closely regulates how much oxygen it receives…and if the levels get too high, it
clamps down the vessels to decrease the amount of blood flow. So, when you inhale high
concentrations of oxygen, the brain says "Wow, too much," and starts to clamp
down. This reaction happens to benefit those with cluster headaches.
So, can use of oxygen cause harm? Yes it can. Oxygen is actually very toxic to the lungs
(as strange as that sounds). Concentrations above 21% (room air), cause damage. Small
amounts of damage can be repaired. At large levels, though, the damage can cause permanent
scarring.
Defining how much the human lung can tolerate without damage is still debated. In fact,
some suggest that previous exposure to high dose oxygen can be protective (increases the
production of the bodies defense mechanisms against free radicals such as oxygen). There
has been good documentation, however, of lung damage done on patients exposed to high dose
oxygen for extended periods of time, some as short as 24hours on 100% oxygen.
So, what does this mean? It means that the long term effects of using oxygen for treating
CHs are not well known. It is advisable, however, to limit each exposure as much as
possible, and not taking in oxygen unnecessarily, such as sleeping with it on.
It is strongly advised that you discuss all of this with your doctor, get a good plan
together about how best to treat your headaches, and if possible, avoiding anything but
medical grade oxygen.
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Imitrex, Zomig, Maxalt, Amerge and Cluster
Headaches
Serotonin is a chemical neurotransmitter in the brain. What that means is
that the brain uses it to send signals across short distances. Sort of like squirting a
cat with a water gun to get it off the furniture. Imitrex (the other medications are
similar) is a serotonin analogue, meaning it looks to the brain a lot like serotonin,
except that it is recognized only by a small portion of the brain.
Imagine, for a moment, all the doors in a building. You could make a master key, one that
would open all of the doors, or a key specific to just a few. Serotonin is the master
key...Imitrex opens only just a few.
Increasing the amount of serotonin everywhere in the brain does not help in the treatment
of headaches. Seems that stimulating some parts helps, others hurt. What was needed was
something that stimulated only those sections that help.
Imitrex, and the other triptans, do just that. They work at the doors labeled 5HT1, doors
that cause constriction of the arteries in the brain...also believed to interact with the
ends of nerves that secrete pain chemicals, decreasing their activity. By doing so, the
medication works quickly, and often effectively, in reducing pain involved with vascular
headaches (clusters and migraines).
The major concern with these medications, however, are that they are not specific enough.
They also stimulate the vessels in the heart to constrict. If already diseased and
narrowed, the constriction can cause chest pain, or worse, a heart attack.
These medications can be tried safely in young adults with no cardiac risk factors. In
older people, or those with risk factors (family history, smoking, cholesterol, obesity,
etc), discussions of the risks and benefits should be undertaken with your doctor, and
possibly the first dose given in the office while undergoing an EKG.
Side effects from long term use are not yet well known, as these medications are
relatively new. Doses of up to two times per week have been well studied, and is currently
the maximum recommended dosing. But that is just because that is all that has been
studied. More frequent dosing is possible, but again, the risks and benefits need to be
discussed with your doctor. Many people, especially those with cluster headaches, feel
that daily dosing is required, and is worth the risk of not knowing the long term
effects...a decision that is made between doctor and patient.
New triptans are being developed as we speak...and many about to be released. One may work
for some, while not for others. Injections (Imitrex only) work within 3-7 minutes, the
nasal spray (Imitrex) within 15-20, and the pills (others) 20-30 minutes.
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Verapamil (Calcium Channel Blockers) and
Cluster Headaches
Verapamil is in a class of medications called calcium channel blockers. It
is considered one of the first line treatments for cluster headaches.
Calcium is used in the body in many ways. Membranes in the body separate cells, line
muscles, and help regulate what goes in and out of spaces in the body. They are the walls
around castles. And like castle walls, they have doors. Doors that will open and close
selectively and let things through. One of these doors allows calcium to flow across the
membrane. In the arteries of the brain, the muscles that cause the arteries to constrict
use calcium to help regulate how hard they squeeze. By blocking the flow of calcium, the
muscles don’t react as quickly.
Cluster headaches seem to involve dilatation of the arteries in the brain. Whether that
causes the pain, or is just a step in the process, we don’t know. However, many of
the medications that relieve cluster headache pain cause constriction of the vessels...so
they definitely play a part. By blocking the calcium channels, the medication, in theory,
decreases the irritability, or responsiveness, of these vessels.
It doesn’t work 100%, as the blockade is not complete (can’t be, you need some
of the calcium channels to beat your heart, etc). But, by decreasing the responsiveness, a
reduction in headache frequency is often seen.
The major side effects of verapamil include constipation (also slows down the muscles
surrounding your intestines), decrease in blood pressure (the vessels in the rest of your
body also relax), as well as a slight decrease in heart rate (the most important muscle of
all). The body does tend to adjust to the blockade slowly, so a gradual increase in doses
is often better than starting high. Because of the above effects, other side effects might
include dizziness upon standing (from lower blood pressure), decrease exercise tolerance
(from decrease heart rate), and fatigue...although these side effects are less common.
Other calcium channel blockers can be effective, but verapamil is the best studied.
Because constipation is usually the only major side effect, it is a safe medication to try
for most people, and as it tends to be very effective, it is one of the first line
treatments against clusters.
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