THE DIFFICULT HEADACHE PATIENT
| CLUSTER HEADACHE AND CRANIAL NEURALGIA —Frederick G. Freitag, DO, Clinical Assistant Professor, Department
of Family Medicine, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago,
IL; Affiliate Instructor, Department of Family Medicine, Chicago College of Osteopathic Medicine, Downers Grove,
IL; Associate Director, Diamond Headache Clinic, Chicago, IL
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| General: headaches occur in groups (related to body’s internal clock); prevalence ≤1%; gender prevalence—progressive
shift from male-dominant disorder to increasing incidence in women; factors affecting shift include changes in serum testosterone
levels, trauma, tobacco and alcohol use, stress, changes in daily routine, and greater female employment
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| Theories on mechanism: sympathetic paresis—studies using carotid angiography suggest that sympathetic branches
traversing carotid artery become compressed as they enter skull because of dilatation of blood vessel (increased blood
flow associated with cluster headache); parasympathetic overstimulation—compelling evidence; based on range of clinical
symptoms and changes in hypothalamic function
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| Presentation: age of onset—late 20s; cases seen in young children and late in life; pattern—majority experience 1 or 2
bouts of closely spaced headaches per year; each bout lasts for several weeks to 3 mo, followed by spontaneous remission
lasting average of 2 yr (shorter or much longer time between bouts possible); signs—ruddy complexion; deep asymmetric
facial creases (especially vertical forehead crease); peau d’orange skin (not as common with decline in smoking); telangiectasia;
broad chin and skull; leonine appearance; rugged features; tallest individual in family; predilection for
brown or hazel eyes; onset of bouts—most common periods of onset ±2 wk from shortest and longest days of year (December
21st and June 21st); bouts of cluster headaches also occur shortly after change of time in spring and fall; circadian
rhythm—during bout, headaches occur around same time (most commonly at night, after patient goes to sleep, near
end of first sleep cycle); predictable in given individual
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| Attack profile: aura rare; onset of pain rapid (10㪧 min to reach peak intensity); duration of headache short (15 min–
1 hr); always unilateral and on same side in given bout; 1 to 3 attacks per day; pain described as excruciating and boring,
often in eye itself or temporal region, not throbbing; partial Horner’s syndrome common (occurs during peak of attack and
remits as attack remits; residual lid drooping between cycles possible in those with long history of cluster headaches); photophobia,
phonophobia, and nausea; scalp and facial tenderness in region of attack; periorbital edema; ipsilateral carotid artery
tenderness (carotidynia; attacks associated with change in carotid blood flow); bradycardia; facial sweating and
flushing
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| Chronic cluster headache: 10% of patients with cluster headaches; loss of circadian and seasonal nature; higher frequency
of attacks; resistant to traditional therapies; loss of effectiveness of preventive therapies
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| Abortive agents: O2 —study showed O2 superior to air in stopping attack; administer 8 to 10 L/min (up to 20 L/min) of
100% O2 by face mask with patient sitting, leaning forward, and breathing normally; antimigraine agents—sumatriptan
(subcutaneous [SC] or intranasal [IN]); dihydroergotamine (IN, SC); zolmitriptan (IN); ergotamine (sublingual, suppository);
anesthetics—aqueous lidocaine (IN) used in emergency department or office setting to anesthetize sphenopalatine
ganglion (nasal decongestant administered first); 5% to 10% cocaine solution (IN)
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| Preventive treatment: antimigraine agents—methylergonovine; ergotamine; long-acting triptans (naratriptan; frovatriptan)
used for “mini prevention” over few weeks to months; corticosteroids—work rapidly to suppress attack when given at
start of cycle; 40 mg prednisone, 1.5 mg dexamethasone po, or 80 mg methylprednisolone (Depo-Medrol); other preventive
medicines used after burst of corticosteroid for long-term control; cyproheptadine (antihistamine with serotonergic
properties); lithium (follow blood levels and address adverse events); verapamil (popular first-choice drug; lecturer prefers
short-acting form for patients with episodic cluster headaches; 240-480 mg qd standard dose); nimodipine (for patients
who respond partially to verapamil but lose response; expensive); divalproex (replacement for lithium; 500 mg effective,
750 mg optimal dose); topiramate (50 mg qd); melatonin (9-10 mg)
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| Refractory cluster headache: intravenous (IV) histamine desensitization (probably works by downregulation of cyclic
guanosine monophosphate [cGMP]/nitric oxide/L-arginine pathway and modulation of perivascular inflammatory response);
sphenopalatine ganglionectomy; radiofrequency denaturization procedures (aimed at trigeminal nerve); glycerol
injections; gamma knife procedures (experience not favorable)
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| Chronic paroxysmal hemicrania: female-predominant; synonyms—icepick headache; stab and jab syndrome; indomethacin-responsive
cluster headache; characteristics—high frequency of attacks; sharp, lancinating pain in temporal region;
unilateral; associated with autonomic phenomena of cluster headaches; brief attacks, compared to most cluster episodes;
occur up to 30 times/day; motion of neck possible trigger; treatment—indomethacin drug of choice; moderate dose used,
then tapered; cyclooxygenase (COX)-2 inhibitors; aspirin; acetazolamide
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| Trigeminal neuralgia: episodic; occurs in elderly more than in younger population; multiple sclerosis coexisting illness
in younger population; unilateral; high-intensity pain (typically divisions I and II of trigeminal nerve); trigger zones
(divisions II and III of trigeminal nerve) ipsilateral to headache pain; triggers unique to individual and include touching
face, cold or hot temperature, biting or chewing; atypical facial pain—lacks trigger zones; pain crosses midline; behavioral
characteristics—patients with cluster headache hold eye and/or press temple; patients with toothache rub area; patients
with temporomandibular joint pain and atypical facial pain massage area; patients with trigeminal neuralgia never
touch site; treatment—lower threshold for performing surgical procedures; preventive medical treatment includes carbamazepine
(Tegretol), phenytoin (Dilantin), baclofen, oxcarbazepine; single-drug regimen preferred, but if double- or
triple-drug regimen required, think surgery
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| SINONASAL DISEASE AND HEADACHE: DIAGNOSIS AND TREATMENT —Howard L. Levine, MD, Director, Nasal
Sinus Center, Marymount Hospital, and Consultant, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland,
OH
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| General: rare to have single sinus involved in pain; sinusitis can cause headache and pain in many areas; myths—sinus
headaches common; all pain in face and forehead is sinus pain; if over-the-counter sinus medications get rid of headache,
headache is sinus
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| Sinus pain: turbinates change throughout day, becoming larger and smaller and when congested, can cause vacuum-type
phenomenon in midface that causes facial pain; causes of turbinate swelling—infection; allergy; inflammation; environmen-tal
irritants; pregnancy; medications; treatment—decongestants; steroids (topical or systemic); antihistamines; anticholinergic
sprays (ipratropium [Atrovent]); surgical treatment to reduce size of turbinates and open outflow tract
includes laser, radiofrequency, and coblation; etiology of pain—nasal turbinates and sinus ostia sensitive because of
greater innervation; sinuses relatively insensitive to pain; pain referred and not just located in area over sinus; pain increases
as congestion increases; middle turbinate curved in c-shape, concavity being medial and narrowing outflow from
sinus into nose; pain from area possibly referred to many regions (eg, forehead, temple)
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| Symptoms: results of study divided symptoms into 2 categories; major—facial pressure; nasal drainage; obstruction;
congestion; taste and smell change; ocular pressure; minor—headache; allergy-type symptoms; symptom improvement
after surgery—facial pressure, eye pressure, and headaches (when associated with other nasal symptoms) alleviated in
74% of patients; when headache only or major symptom, study showed alleviation of symptom unusual (conclusion that
headache caused by something else)
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| Definitions: acute sinus headache (International Headache Society [IHS])—purulent discharge; simultaneous onset of
headache and sinusitis; abnormalities on plain x-ray, computed tomography (CT), or transillumination (very little value);
location of headache over sinus itself; definition supposes sinusitis already present; clinical definition of rhinosinusitis—
presence of 2 of nasal blockage, congestion, olfactory alteration, discharge, facial pain and pressure, and either endoscopic
signs of polyps, mucopurulent discharge from middle meatus, edema, or mucosal changes on CT; acute sinusitis defined as
duration of <12 wk, with complete resolution; persistent or chronic defined as duration ≥12 wk, with no resolution; another
definition—major criteria include facial pressure/pain, congestion/fullness, obstruction/blockage, nasal discharge/postnasal
drip, change in taste and smell, and purulence; minor criteria include headache, fever, halitosis, fatigue, dental pain,
cough, and ear pain and pressure; diagnosis of rhinosinusitis made if strong history includes 2 major criteria, 1 major and 2
minor, or purulence on examination; single minor criterion, ie, headache, does not fit definition of rhinosinusitis; lacking in
sinus headache definition—definition of pain or pressure; location, frequency, and severity of headache; classification—
acute sinusitis (<4 wk); recurrent acute; subacute (4㪤 wk); chronic (>12 wk); acute exacerbations of chronic sinusitis
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| Acute rhinosinusitis: fever or facial pain does not constitute diagnosis in absence of other nasal symptoms; treat with
antibiotics if worse after 5 days or symptoms >10 days; over-the-counter (OTC) treatment with mucolytic (eg, guaifenesin)
or saline helpful in viral infection; abnormalities on CT common early in course and do not indicate bacterial infection
and need for antibiotics (CT abnormalities present 48-96 hr into any acute respiratory infection)
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| Chronic rhinosinusitis: sinus opacification; facial pain does not constitute suggestive history in absence of other signs
and symptoms; plain x-rays of sinuses of limited value in acute and recurrent acute rhinosinusitis if air-fluid level present
and of no value in chronic rhinosinusitis
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| Medical management: decongestants (topical and systemic); mucolytics; antibiotics (when needed); steroid nasal
sprays if patient has allergies; systemic steroids (polyps as cause); antihistamines not used, except when allergy suspected
(thicken and dry secretions, making sinus drainage more difficult)
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| Bacteriology: Streptococcus pneumoniae and Haemophilus influenzae most common organisms in acute rhinosinusitis;
Staphylococcus aureus most common organism in chronic rhinosinusitis; antibiotic treatment for acute rhinosinusitis—
amoxicillin; amoxicillin-clavulanate; cefpodoxime; sulfonamide, doxycycline, macrolide, or ketolide if patient allergic to
β-lactams; switch to different antibiotic if no improvement in 5 days (higher-dose amoxicillin-clavulanate [if patient initially
on amoxicillin] or fluoroquinolone); antibiotics for chronic rhinosinusitis—none approved by Food and Drug Administration
(FDA); antibiotic choice based on bacteriology (S aureus and Pseudomonas most common organisms);
endoscopy-guided biopsy for culture and sensitivity possibly necessary; duration of therapy increased to 14 to 28 days
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| Indications for surgery: nasal polyposis; failure of medical management; unmanaged lower respiratory tract disease
(eg, asthma); complications of sinusitis (eg, orbital abscess)
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| Contact-point headaches: relationship between contact-point headaches and migraine triggers; history of chronic
headache; lack of chronic inflammation; absence of other headache causes; presence of contact points on endoscopy or
CT; failed medical therapy; relief of headache with topical anesthesia (eg, lidocaine [Xylocaine]); concept not fully understood
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| Sinus headache vs migraine: undiagnosed migraine sufferers often receive diagnosis of sinus or tension headache
when number of people with true sinus headache actually small; nasal sinus symptoms common in both migraine and sinus
headache because of neurology and association between trigeminal nucleus caudalis and innervation of face; 15% of
patients with primary headache have abnormal CT; 20% of patients with sinusitis have unrelated headache; sinus-related
pain—bilateral (91%), unilateral (8%); pain present days vs hours; 78% of patients say pain worse when bending over;
29% of patients report relief with antihistamines and decongestants; associated symptoms include nasal obstruction, discolored
nasal drainage, change of sense of taste and smell, and cough; visual disturbance rare; sinus headache overdiagnosed,
antibiotics and surgery overused
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| Criteria for sinus headache: dull, pressure-like pain; bilateral; periorbital; unilateral with deviated septum, unilateral
sinus disease, or turbinate congestion; radiation into ears; usually worse in morning, better as day progresses; nasal congestion;
lasts for days at time, but rarely majority of month; abnormal CT; positive findings on nasal endoscopy; not associated
with nausea, vomiting, or visual disturbances; no relationship between severity and site of pain; no correlation
between CT and severity of pain; when headache only symptom or major symptom, cause almost never sinusitis
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| SUBJECTIVE HEADACHE BEFORE AND AFTER ENDOSCOPIC SINUS SURGERY —William H. Moretz, III, MD,
Department of Otolaryngology, Medical College of Georgia, Augusta
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| Study: purpose—to study prevalence of subjective headache in patients diagnosed with chronic rhinosinusitis, demonstrate
effect of endoscopic sinus surgery on subjective headache scores, and study relationship of headache scores in patients
with and without nasal polyps; design—prospective; 201 patients; 3-yr period; diagnosis of chronic rhinosinusitis; patients
treated for 3 wk with medical management before CT ; nasal polyps present in 78 patients; headache and sinonasal
outcomes test mean scores compared preoperatively and at 2 yr postoperatively; results—mean subjective headache
scores in patients without polyps preoperatively higher than those with polyps; overall, subjective headache scores decreased
from mean of 4.7 to 0.8 after endoscopic sinus surgery; 92% of patients with headache symptoms and chronic rhinosinusitis
showed some improvement 2 yr after endoscopic sinus surgery
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Educational Objectives
| The goal of this program is to provide the listener with information on cluster headaches, the diagnosis and management of
sinonasal disease producing headache, and subjective headache before and after endoscopic sinus surgery. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Discuss the nature of cluster headaches, chronic paroxysmal hemicrania, and trigeminal neuralgia.
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| 2. Recognize and treat cluster headaches.
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| 3. Discuss criteria for diagnosing rhinosinusitis.
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| 4. Provide treatment for a patient with rhinosinusitis.
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| 5. Discuss data on subjective headache in patients before and after endoscopic sinus surgery.
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Discussed on This Program
Acetazolamide [Dazamide, Diamox, Diamox Sequels]
Amoxicillin [several trade names]
Amoxicillin and potassium clavulanate (co-amoxiclav) [Augmentin, Augmentin ES-600, Augmentin XR]
Baclofen [Lioresal, Lioresal Intrathecal]
Carbamazepine [Carbatrol, Epitol, Tegretol, Tegretol-XR]
Cefpodoxime proxetil [Vantin]
Cocaine [Cocaine HCl, Cocaine Viscous]
Cyproheptadine HCl
Dexamethasone (several trade names)
Dihydroergotamine mesylate [D.H.E. 45, Migranal]
Divalproex sodium [Depakote, Depakote ER]
Doxycycline (several trade names)
Ergotamine tartrate [Ergomar]
Frovatriptan succinate [Frova]
Guaifenesin (glyceryl guaiacolate) [several trade names]
Indomethacin [Indocin, Indocin SR, Indomethacin SR, Indomethacin Extended-Release]
Ipratropium bromide [Atrovent]
Lidocaine HCl [several trade names]
Lithium [Eskalith, Eskalith CR, Lithobid, Lithonate, Lithotabs ]
Melatonin
Methylergonovine maleate [Methergine]
Methylprednisolone acetate (several trade names)
Methysergide maleate [Sansert] (discontinued)
Naratriptan HCl [Amerge]
Nimodipine [Nimotop]
Oxcarbazepine (oxycarbamazepine) [Trileptal]
Phenytoin [Dilantin Infatab, Dilantin-125]
Prednisone (several trade names)
Sumatriptan succinate [Imitrex]
Topiramate [Topamax]
Verapamil HCl [Calan, Calan SR, Covera-HS, Isoptin SR, Verelan, Verelan PM]
Zolmitriptan [Zomig, Zomig-ZMT]
Suggested Reading
Baraniuk JN, Maibach H: Pathophysiological classification of chronic rhinosinusitis. Respir Res 6:149, 2005;
Bhatti MT, Patel R: Neuro-opthalmic considerations in trigeminal neuralgia and its surgical treatment. Curr Opin Ophthalmol
16:334, 2005; Cady RK, et al: Sinus headache: a neurology, otolaryngology, allergy, and primary care consensus
on diagnosis and treatment. Mayo Clin Proc 80:908, 2005; Canavero S, Bonicalzi V: Drug therapy of trigeminal
neuralgia. Expert Rev Neurother 6:429, 2006; Coffey CS, et al: Endoscopically guided aerobic cultures in postsurgical
patients with chronic rhinosinusitis. Am J Rhinol 20:72, 2006; Cohen AS, et al: Paroxysmal hemicrania in a family.
Cephalalgia 26:486, 2006; Copeland B: Microvascular decompression for trigeminal neuralgia in the elderly: a review
of the safety and efficacy. Neurosurgery 58:E799, 2006; Desrosiers M, et al: Management of acute bacterial rhinosinusitis:
current issues and future perspectives. Int J Clin Prac 60:190, 2006; Eloy P, et al: Management of chronic rhinosinusitis
without polyps in adults. B-ENT Suppl 1:64, 2005; Fried MP, et al: Chronic sinusitis: a surgical perspective.
Allergy Asthma Proc 27:26, 2006; Hadley JA: Value of short-course antimicrobial therapy in acute bacterial rhinosinusitis.
Int J Antimicrob Agents 26:S164, 2005; Huang WH, Hung PK: Methicillin-resistant Staphylococcus aureus infections
in acute rhinosinusitis. Laryngoscope 116:288, 2006; Mehle ME, Schreiber CP: Sinus headache, migraine, and
the otolaryngologist. Otolaryngol Head Neck Surg 133:489, 2005; Smith TL, et al: Predictive factors and outcomes in
endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope 115:2199, 2005; Smith TL, et al: Evidence supporting
endoscopic sinus surgery in the management of adult chronic rhinosinusitis: a systematic review. Am J Rhinol 19:537,
2005; Zebenholzer K, et al: Facial pain in neurological tertiary care centre—evaluation of the international Classification
of Headache Disorders. Cephalagia 25:689, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Freitag has received grants and/or conducted research for Allergan, AstraZeneca, GlaxoSmithKline, Merck and
Co., and Ortho-McNeil Pharmaceuticals. He has served as a consultant to Allergan, AstraZeneca, Ortho-McNeil Pharmaceutical,
Valeant Pharmaceuticals, and Vendanta Research. He has served on the speaker’s bureau of AstraZeneca, GlaxoSmithKline,
Ortho-McNeil Pharmaceuticals, Pfizer, and Valeant Pharmaceuticals. Dr. Levine is medical director for
Sinucare and a consultant for MedTronic Xomed.
Drs. Freitag and Levine were recorded at the 19th Annual Practicing Physician’s Approach to the Difficult Headache Patient,
held February 14-18, 2006, in Rancho Mirage, CA, presented by Diamond Headache Clinic Research and Educational
Foundation and Diamond Inpatient Headache Unit at Thorek Memorial Hospital and sponsored by the
Chicago Medical School at Rosalind Franklin University of Medicine and Science. Dr. Moretz was recorded at the
Annual Combined Otolaryngological Spring Meetings (COSM) Conference of the American Rhinologic Society, held May
13-16, 2005, in Boca Raton, FL. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
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