Cluster Headache: Signs, Symptoms, Causes, Risk Factors, Triggering Factors, Diagnosis, Preventions and Treatments

Primary Headaches - Cluster Headache: Signs, Symptoms, Causes, Risk Factors, Triggering Factors, Diagnosis, Preventions and Treatments By Kyle J. Norton

Please note that all articles written by Kyle. J. Norton are for information and education only, please consult with your doctor or related field specialist before applying.

I. Cluster HeadacheCluster Headache also known as suicide headache is defined as an uncommon distinctive neurovascular syndrome occurring in either episodic or chronic patterns of that occur periodically over a long period of time. The diseases affects over 0.1% of the population, occurring at 45-to 60-day intervals with one to three headaches a day lasting 45 min to 2 h(a), if untreated it, can cause increased frequency of the attacks.

II. Signs and Symptoms  1. Pain Pain is more intensify compared with other types of headache. Dr. Peter Goadsby, Professor of Clinical Neurology at University College London, commented:  "Cluster headache is probably the worst pain that humans experience. I know that’s quite a strong remark to make, but if you ask a cluster headache patient if they’ve had a worse experience, they’ll universally say they haven't. Women with cluster headache will tell you that an attack is worse than giving birth"(b)

2. Anxiety and depressionResearchers suggested that  Cluster headache (CH) patients who were depressed or anxious were more likely to present at a younger age and have attack-related nausea and prodromal symptoms. Depressed CH patients were also more likely to have another pain disorder and had undertaken twice as many prophylactic medication trials(1)

3.  Unilateral headaches and extreme intensityIn the study conducted by Mayo Clinic College of Medicine, cluster

headache attacks are stereotypical, that is, of extreme intensity, of short duration, occurring unilaterally, and associated with robust signs and symptoms of autonomic dysfunction. Unlike migraine, during an attack the patient with cluster headache often paces about. Attacks frequently occur at night, awakening the patient from sleep(2)

4. Sense and behaviour of restlessness In the study of comprised 86 consecutive new cluster headache patients (68 males, 18 females; mean age, 38.4 ± 12.2 years; range, 17-73 years). result showed a relatively low prevalence of chronic cluster headaches, and uncoupling of a sense of restlessness and restless behaviour(5)

5. Tearing and RhinorrheaTearing and Rhinorrhea are trigeminal-autonomic headache symptoms as a result of symptoms of autonomic dysfunction, occurred during the attacks of cluster headache(7)

6. Facial and eye pain Facial and eye pain  are associated with the autonomic innervation of the eye and orbit asa result of cluster headache debilitating conditions.(12)

7. Facial pain In a study by Dr. Oomen KP and the tead suggested that correct headache and facial pain diagnosis is vital to assess the outcome of different treatment strategies. Even in a tertiary center, headache and facial pain can be misdiagnosed. RFT of the SPG may be effective in patients with facial pain(8)

8.  Other symptoms also include the followinga. Ipsilateral conjunctival injection and/or lacrimationb. Ipsilateral nasal congestion and/or rhinorrhoeac. Ipsilateral eyelid oedemad. Ipsilateral forehead and facial sweatinge. Ipsilateral miosis and/or ptosisf. A sense of restlessness or agitation(9)

8. Etc.

Although most cluster headache patients are experiences certain  symptoms of autonomic dysfunction as the connection of cluster headache (CH) attacks with rapid eye movement (REM) sleep has been suggested by various studies, in some patients Cluster headache attacks are found no association of CH with REM or sleep disordered breathing was observed. Increased heart rate temporally associated with transition from one sleep state to another was observed before patients awoke with headache. Total sleep time, total wake time, arousal index and distribution of non-REM sleep stages were different between chronic and episodic CH(4). Other study showed that patients with cranial autonomic symptoms (CAS)were experience no pain in CH attacks, whereas another five patients continued to experience typical cluster headaches(6)

III. Risk factors 1. GeneIn the review of only genetic studies with limited sample sizes have been performed, but results have indicated an association with the HCRTR2 gene, which is involved in the regulation of chronobiological rhythms(c). Other suggested that cluster headache has an autosomal dominant gene with a penetrance of 0.30 to 0.34 in males and 0.17 to 0.21 in females. The gene is present in 3% to 4% of males and 7% to 10% of females with cluster headache(f)

2. GenderMen are at higher risk than women in development of cluster headache(d)

3. Family history In the study of California Medical Clinic For Headache, found that three generations of cluster headache were found in 7/24 kindreds (29.17%). Parental cluster headache was found in 19 of the 24 probands (79.17%); in 14/19 (73.68%), transmission was from father to proband. fifty percent of cluster probands also had migraine headaches, and almost 50% had a family history of migraine. Similarly, of the larger population of 300 cluster patients, approximately 45% had a positive family history of migraine. f 1652 relatives of all cluster patients, 3.45% had cluster headache (thirteen times the expected frequency of cluster headache in the general population) and 17.55% had migraine headaches(g)

4. Age

Cluster headache is commonly considered to be a young-male disorder, but middle-aged and elderly women may also be affected. The characteristics of the pain and its manner of occurrence were similar in our cases to those reported in the young-male population(e)

IV. Causes1. Chronic headachePaitent who have chronic headache may see their diseases evolved into chronic cluster headache with a milder chronic headache in-between the severe cluster headache attacks as a result of trigeminal nerve root compression(3)

2. Parasympathetic pathwaySome researchers suggested that the internal carotid artery (ICA) with proximal pial and orbital-periorbital branches, as well as external carotid vessels adjacent to the orbital region, are involved in the autonomic symptoms of an attack of cluster headache. Dilation of the intracranial ICA due to activation of this parasympathetic pathway may aggravate pain (10)

3. Post-traumatic headache (PTH) In the study conducted by The National Hospital for Neurology and Neurosurgery, researchers suggested that a better understanding of the association between head trauma and CH may provide important insights into both the pathophysiology of CH and the mechanisms by which traumatic head injury predisposes patients to developing headaches(11)

4. Arrhythmias Arrhythmias is defined as a condition of of the heart rate (pulse) or heart rhythm, such as beating too fast (tachycardia), too slow (bradycardia), or irregularly

5. Sleep disordersleep disorders may themselves trigger headache attacks and can be symptoms of other underlying pathologies(13)

6. Serotonina type of neurotransmitter, passes messages between nerve cells, low serotonin levels in the brain may increase the risk of the process of constriction of the blood vessels as it alters levels of dopamine and stress hormones, and may be part of a complex cellular membrane trafficking

dysfunction involving not only the serotonin transporter but also other transporters and ion channels of which trigger a migraine (14)

7. Block sodium channelIn the study of "Cluster headache with Brugada electrocardiogram pattern" conducted by University of Fukui, recommended therapies without sodium channel blocking effect were failed in a 40-year-old male with CH whose ECG shows Brugada ECG pattern, clonazepam and codein phosphate, which are exceptional treatments for CH, were effective for severe unilateral orbital pain(15)

8. Posterior hypothalamusIn a study conducted by University Hospital Central de Asturias, researchers suggested that theefficacy of DBS in very refractory CCH with a slightly modified hypothalamic target conceived to avoid the lateral ventricle wall so as to extend the stimulated brain area and to decrease the morbidity of potential haemorrhagic complications(16)

9. Histamine  Some researchers suggested that histamine may be associated to the in the pathogenesis of cluster headache , but other study found that there are no association with histamine, in a double-blind crossover trial of a combined histamine H1 and H2 antagonist treatment(17)

10. Granulomatous pituitarysome studies suggested that the association between cluster headache and granulomatous enlargement of the pituitary gland.(30)

V. What trigger cluster headaches1.  Smoking, alcohol consumption, and head traumamany researchers believe that  smoking, alcohol consumption, and head trauma triger the onset of cluster headache but accoring to the study conducted by Karolinska University Hospital Huddinge, suggested that formerly described demographic relationships in CH regarding cigarette smoking, alcohol consumption, and head trauma were also seen in our CH patients and their nonaffected relatives. These findings might represent a gene environment interaction in affected CH patients or it could be personality-lifestyle-related phenomena or a combination of these mechanisms(19)     

2. Other triggering factorsBeside the causes above, out of 126/179 replies, other factors triggering migraine attack include too much work (under the stress category 54/64), reflected sunlight (under the light category 35/44), too little sleep (under the sleep category 19/24), red wine (under the alcohol category 20/22), passive smoking (under the smoke category 11/11), menstruation (under the menstruation or break from the pill category 12/14) and perfume (under the fumes/heavy scents category 12/15). Hormones, light and stress were reported to cause at least 50 % of MA attacks in 62%, 47% and 42% of participants, respectively. No participants reported alcohol to be the trigger of 50% or more of their attacks. In the groups of participants with "light", "fumes/heavy scents", "smoke" or "physical effort" as triggers, nearly all patients reported that an exposure time to the trigger of less than 3 hours (90-100% of patients) was necessary to trigger an attack and a latency to onset of attack of less than 3 hours (90-100% of patients) in the study conducted by University of Copenhagen and Glostrup Hospital, Denmark J. (20)

3. Medication-overuse headache (MOH) In the study of Ghent University Hospital, Dr. Paemeleire K and the team suggested that a personal or familial history of migraine appears to be strongly associated with the development of MOH in CH, at least with the phenotype of background headache(21)

4. CoccaineCluster headache usually appeared 1 to 2 hours after cocaine consumption, though it disappeared 5 to 10 minutes after again inhaling the drug(22)

5. Nitric oxide pathwaySome researchers suggested that Nitric oxide (NO) may participate in the mechanisms underlying vascular headaches, but in the study of conducted by University of Pavia, data of the study do not support the presence of a basal hyperactivity of the L-arginine-NO pathway in CH patients. Increased NO production may be of importance in the mechanisms leading to CH attacks, but other factors are likely to render CH patients hyperresponsive to NO, and ultimately to cause the occurrence of pain and associated features(26)

VI. Tests and diagnosisA. Misdiagnosis In a study conducted of Vast Majority of Cluster Headache Patients Are

Initially Misdiagnosed, Dutch Researchers Report of a total of 1163 participants completed and returned the second questionnaire (913 men, 250 women). Only 22% said they were initially diagnosed with CH. Twenty-one per cent were initially diagnosed with sinusitis, 17% migraine, and 11% with a dental related condition. Sixteen percent had made the CH diagnosis themselves after reading about the symptoms. Sixteen percent had undergone tooth extraction and 12% an ears, nose and throat operation as treatment for their headachesYour health care provider can diagnose this type of headache by performing a physical exam and asking questions about your symptoms and medical history, In their report, published in the Journal of Neurology Neurosurgery and Psychiatry in August 2003, Dr. van Vliet and colleagues say that clinical symptoms such as sensitivity to light, nausea and vomiting most likely lead physicians to diagnose migraine even though they are also common CH symptoms (23)

B. DiagnosisDiagnosis depending to the symptoms of the diseases, including medical history, physical exam, pattern of recurrent attacks, and by cardinal symptoms (swollen eyelid, watery eye, runny nose). Keeping a headache attacks diary, etc. will help a physician to rule out other types of headaches. As The attacks are stereotypic--they are of extreme intensity and short duration, occur unilaterally, and are associated with robust signs and symptoms of autonomic dysfunction. Although the pathophysiology of cluster headache remains to be fully understood, there have been a number of recent seminal observation(24)If a physical exam is done within 48h of last attack, patients who had pain episodes mimicking cluster headache attacks, and who experienced a total or partial Horner's syndrome ipsilaterally to pain (25)

C. Types of diagnosisThe aim of the diagnosis is to rule other causes of the diseases1. CT scanCT scan can dive your doctor a three-dimensional view of your blood vessels of the brain to look for masses and other abnormalities  that cause migraine headache

2. Magnetic resonance imaging (MRI)By using radio waves and magnetic fields to take pictures, MRI scan provides very high quality of a cross-sectional slice and lengthwise slices of

the brain and thus providing the better and detail image of location of tumor and the surrounding structures. It is one of most likely early test ordered by a doctor to diagnose tumors, strokes, aneurysms, neurological diseases and other brain abnormalities and the blood vessels around the brain.

3. Spinal tap (lumbar puncture)A spinal tap is a procedure performed when a doctor needs to look at the cerebrospinal fluid (also known as spinal fluid), by inserting a thin needle between two vertebrae in your lower back to extract a sample. If your doctor suspects the onset of migraine headache is caused by inflammation of the membranes and cerebrospinal fluid surrounding your brain and spinal cord

4. Etc.

VII.  Other conditions similar to cluster headache1. Migraine headacheMigraine headache is one most common headaches defined as condition of chronic neurological disorder. The pain of the headache is intense, throbbing from moderate to severe, may be bilateral or unilateral at the onset, and occur on one side or alternate sides from one attack to the next. Something a cluster headache does not do. Unlike migraine, during an attack the patient with cluster headache often paces about. Attacks frequently occur at night, awakening the patient from sleep. Cluster headaches usually appear suddenly without warning. Cluster headache is more common in middle-aged men, migraine is more common in young women.

2. Trigeminal neuralgia  Trigeminal neuralgia is defined as condition of is a nerve disorder causes of stabbing or electric-shock-like pain in sudden of one-sided, intense facial painthe face,  lasts for only a few seconds to a couple of minutes, but can also be a long-term problem.

3. Chronic paroxysmal hemicrania (CPH) Chronic paroxysmal hemicrania (CPH) is also known as Sjaastad syndrome caused short headache attacks of which respond well to indomethacin. The pain in chronic paroxysmal hemicrania (CPH) is unilateral, always affects the same side, and is generally oculofrontotemporal in location, but mostly in women.

4. Etc.

VIII. PreventionA. Do's and Do not's list, if you are experience migraine headache because of foods, food additives, chemical compounds, alcohol, smoking, stress, life style, etc.

1. Food elimination dietCertain foods which trigger the over production of IgG antibodies if eliminated from the diet can result in the decreased number of migraine like headaches over 4weeks, some studies suggested that using the ELISA test with subsequent diet elimination advice significantly reduce the number of migraine like headaches at 4 weeks.(34)2. Diet restriction Diet restriction based on IgG antibodies is an effective strategy in reducing the frequency of migraine attacks. In the study conducted by Istanbul Faculty of Medicine, Department of Neurology, Istanbul, Turkey in a 6-week baseline, IgG antibodies against 266 food antigens were detected by ELISA(35)

3. Foods and chemical compounds trigger migraine headachea. Certain foods can trigger the migraine headache attack through an allergic reaction. Citrus fruits, tea, coffee, pork, chocolate, milk, nuts, vegetables and cola drinks have been cited as possible allergens associated with migraine. If you are experience the attack after taking some of those, the best way is to avoid them. Researchers also suggested that substances are tyramine, phenylalanine, phenolic flavonoids, alcohol, food additives (sodium nitrate, monosodium glutamate, aspartame) and caffeine may be the cause of modifications in vascular tone and bring migraine on(36)4. Alcohol As we all known that a small dose of alcohol increase the protective effect on cardiovascular disease, but excessive drinking can increase the frequency of migraine headache as alcoholic drinks are a migraine trigger in about one third of patients with migraine in retrospective studies on trigger factors(37)5. SmokingThere is evidence that migraine was associated with several lifestyle and socioeconomic factors, In the investigation conducted by University of Copenhagen with a questionnaire containing validated questions to diagnose migraine and questions on lifestyle and socioeconomic factors was sent to 46,418 twin individuals residing in Denmark. 31,865 twin individuals aged 20-71 and most associations such as low education and employment status

were probably due to the negative effects of having migraine while others such as smoking were risk factors for migraine.(38)

6. Others may trigger headache migraine attacks to certain people, such asa. Too much work (Stress)b. Too little sleep (Sleep related)c. Passive smoking (Smoking)d. Perfume (Chemical compound)e. Etc.(39)7. Moderate exerciseIn a study of Forty women with general migraine attending the Neurology Department of the Faculty of Medicine Faculty of Dokuz Eylül University, regular long-term aerobic exercise is found in reduced migraine pain severity, frequency and duration possibly due to increased nitric oxide production.(40)

8. Management of migraineHygiene and behaviour measures capable of ensuring the best possible well-being (regular meals and balanced diet, restriction of alcohol and smoking, regular sleeping pattern, moderate physical exercise and relaxation) have found to reduce the frequent migraine attack(41)

9. Avoid medication overuse headache (MOH)There are report that overuse of migraine medication can result of increased frequency to daily or near-daily as a rebound effect comes into play(42)

10. Etc.

B Nutritional Supplements for Migraine Headache1. MagnesiumSome studies indicated that deficiency of magnesium is associated with patient with migraine headache as may promote cortical spreading depression, affecting serotonin receptor function, and influence synthesis and release of a variety of neurotransmitters and suggested that empiric treatment with at least oral magnesium is warranted in all migraine sufferers.(43)

2. CalciumCalcium deficiency can lead to Hypocalcemia, a serum level of calcium that

is below normal, it is manifested by increased neuromuscular irritability, leading to neuromuscular hyperexcitability, anxiety, dysautonomia, oculofrontal headache and migraine(44)

3. DLPA (DL-phenylalanine)DL-phenylalanine, an essential amino acid of which is important for our body converts phenylalanine to tyrosine, another amino acid then to epinephrine and norepinephrine, which are important brain chemicals called neurotransmitters. Some researchers suggest that DL-phenylalanine (DLPA) appears to potentiate pain relief and also ease depression in patients receiving opiates for chronic non-malignant pain(46)

4. Vitamin B2Riboflavin therapy supplemented may be appropriate alternatives in patients with migraine disorder as it significant decreases in headache frequency, intensity, duration and medication intake (45)

5. MelatoninSerotonin, a type of neurotransmitter, passes messages between nerve cells, low serotonin levels in the brain may increase the risk of the process of constriction of the blood vessels as it alters levels of dopamine and stress hormones, and may be part of a complex cellular membrane trafficking dysfunction involving not only the serotonin transporter but also other transporters and ion channels of which trigger a migraine (47)

6. Coenzyme Q 10 (CoQ10)In some studies found that deficiency of CoQ10 are common in pediatric and adolescent migraine, but determination of deficiency and consequent supplementation may result in clinical improvement and involving more scientifically rigorous methodology to confirm this observation.(48)

7. Omega 3 fatty acidsDiet with long-chain n-3 polyunsaturated fatty acids might reduce frequency and severity of migraines in adolescents in astudy conducted by Divisions of Adolescent Medicine. Dr. Harel Z, and the team also said that results of this preliminary study suggest that both fish oil and olive oil may be beneficial in the treatment of recurrent migraines in adolescents. Further studies are warranted to compare each of these treatments with other interventions.(49)

8. Etc.

C. Diet for cluster headacheCertain diet may trigger the attack of migraine headache as a result of allergic reaction in certain people, but it may be helpful to people who are experience migraine headache with no allergic effects1. WaterWater, an essential for the body’s proper functioning, and dehydration may trigger the migraine attack. Un a study of Fifty migraineurs were asked if insufficient fluid intake could provoke their migraine attacks conducted by The City of London Migraine Clinic, twenty replied "yes," 7 were doubtfully positive, and 23 said "no." In addition 14 of 45 migraineurs at a meeting of the British Migraine association (UK) also recognized fluid deprivation as one of their migraine triggers.(50) Adding fluid deprivation to migraine patient may reduce the numbers of migraine attacks.

2. Fish oil and Olive oilOmega-3 PUFA, from fish oil-eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been studied to consist anti-inflammatory properties of which are useful in the management of inflammatory and autoimmune diseases, including rheumatoid arthritis, Crohn's disease, ulcerative colitis, psoriasis, lupus erythematosus, multiple sclerosis and migraine headaches.(51)

3. BroccoliBroccoli is a very good source of magnesium and a good source of calcium. Magnesium, plays an essential in many intracellular processes and in migraine pathogenesis, low levels of magnesium may promote cortical spreading depression, hyperaggregation of platelets, affect serotonin receptor function, and influence synthesis and release of a variety of neurotransmitters of which can trigger migraine headache(52)

4. SardinesSardines contain measurable amount of Omega 3 fatty acid, calcium and CoQ10 of which can be helpful in reducing the frequency of migraine headache (53)(54)

5. SpinachSpinach is an excellent source of both calcium, magnesium, vitamin B2

(riboflavin)Riboflavin therapy supplemented may be appropriate alternatives in patients with migraine disorder as it significant decreases in headache frequency, intensity, duration and medication intake (55)

6. Mustard GreensThe World's Healthiest Foods recommends mustard greens as an excellent source of calcium and a very good source of magnesium of which are important in preventing and treating migraine headache (56)(57))

7. FishBeside rich in Omega 3 fatty acids, all fish contain more or less DL-phenylalanine, an essential amino acid of which is important for our body converts phenylalanine to tyrosine, another amino acid then to epinephrine and norepinephrine, which are important brain chemicals called neurotransmitters. Some researchers suggest that DL-phenylalanine (DLPA) appears to potentiate pain relief and also ease depression in patients receiving opiates for chronic non-malignant pain(58)

8. Etc.

For The World Most Healthy Foods, please visit http://healthy-foods-index.blogspot.ca/2011/03/healthy-foods-list.html

IX. TreatmentsA. In conventional medicine perspectiveA.1. Non medical treatment1. Testosterone replacement therapy  Women and men with abnormal testosterone levels causes of cluster headache may be treated with Testosterone replacement therapy. In the study conducted by Department of Neurology, Cleveland Clinic Foundation, abnormal testosterone levels in patients with episodic or chronic cluster headaches refractory to maximal medical management may predict a therapeutic response to testosterone replacement therapy. In the described cases, diurnal variation of attacks, a seasonal cluster pattern, and previous, transient responsiveness to melatonin therapy pointed to the hypothalamus as the site of neurological dysfunction(27)

2. Melatonin as adjunctive therapy

The use of melatonin as adjunctive therapy has been reported in patients with cluster headache who have incomplete relief of their headaches on conventional therapy. In the study by Montreal Neurological Institute, McGill University, patients with chronic cluster headache or patients with episodic cluster headache whose headaches are uncontrolled on conventional therapy do not appear to gain therapeutically from the addition of melatonin to their usual treatment regimens. It is perhaps the phase-shifting properties of melatonin that mediate its effect in patients with episodic cluster headache, and it may be necessary to treat from the beginning of the cluster bout to reset the circadian pacemaker, thus producing a more positive outcome(28)

3. Glucocorticoid therapyGlucocorticoid therapy has been a well-recognized abortive treatment for cluster headaches.  In the study conducted by Department of Neurology, The Cleveland Clinic Foundation, Accumulated evidence suggests sympathetic dysfunction--embodied in the Horner sign so commonly seen in the cluster headache--as a necessary ingredient in the inception of the cluster headache. Sympathetic dysfunction now is thought to be associated with the hypercortisolism, hypotestosteronism, and lower-than-normal melatonin levels in the active cluster patient. Future research may hold the key to a fuller explanation of the complex interaction of hormonal systems in the cluster headache(29)

4. Oxygen therapy Oxygen therapy has been well known to be used in treating cluster headache. Hyperbaric oxygen therapy (HBOT)was effective for the termination of acute migraine in an unselected population, and weak evidence that NBOT was similarly effective in cluster headache. Given the cost and poor availability of HBOT, more research should be done on patients unresponsive to standard therapy. NBOT is cheap, safe and easy to apply, so will probably continue to be used despite the limited evidence in this review(31)

5. Etc.

A.2 Surgical treatmentIf Chronic cluster headache, also known as chronic migrainous neuralgia, is unresponsive to medical treatment. Surgical treatment may be another choice as some researchers suggested that trigeminal ablative procedures

might have a dual role in the relief of medically intractable cases, by directed against either the trigeminal nerve or the nervus intermedius/greater superficial petrosal (NI/GSP) pathway. Among 26 patients who underwent posterior fossa trigeminal sensory rhizotomy or percutaneous radio-frequency trigeminal gangliorhizolysis at our institution, relief of pain was excellent in 14 (54%), fair to good in 4 (15%), and poor in 8 (31%)(32). AS Trigeminal operative procedures are not consistently helpful in chronic cluster headache, while NI section has been shown to give potentially long lasting relief but carries the potential risks of cerebellopontine angle surgery(33)

A.3. MedicationA.3.1. Preventive medicine 1. Prophylactic medicinesa. Calcium channel blocker (Verapamil) European guidelines suggest the use of calcium channel blocker verapamil the at a dose of at least 240 mg daily. In the study of higher doses conducted by Pôle Neurosciences Cliniques du CHU de Nice, CH patients treated with verapamil VHD (≥720 mg) were considered with a systematic electrocardiogram (EKG) monitoring. Among 200 CH patients, 29 (14.8%) used verapamil VHD (877±227 mg/day). Incidence of EKG changes was 38% (11/29). Seven (24%) patients presented bradycardia considered as nonserious adverse event (NSAE) and four (14%) patients presented arrhythmia (heart block) considered as serious adverse event (SAE). Patients with EKG changes (1,003±295 mg/day) were taking higher doses than those without EKG changes (800±143 mg/day), but doses were similar in patients with SAE (990±316 mg/day) and those with NSAE (1,011±309 mg/day). Around three-quarters (8/11) of patients presented a delayed-onset cardiac adverse event (delay ≥2 years). Our work confirms the need for systematic EKG monitoring in CH patients treated with verapamil. Such cardiac safety assessment must be continued even for patients using VHD without any adverse event for a long time.(59)

b. Side effects are not limit to* Dizziness* Fatigue * Headache and lightheadedness* Redness, or swelling at the injection site* allergic reactions, such as as rash, hives; itching, in some cases difficulty breathing

* Irregular heartbeat* Etc.

2. Steroids a. Steroid such as prednisolone/prednisone, are also effective, but patient may have to take the medicine with a high dose  in longer time up to 6 months, but recurrence is frequent and may lead to steroid-dependency. Some researchers found that a single suboccipital steroid injection completely suppresses attacks in more than 80% of CH patients. This effect is maintained for at least 4 weeks in the majority of them(60)b. Side effects *  Orally ingested steroids can affect the liver and in severe case can cause liver damage*  Steroids can increased levels of LDL* leading to increased level of estrogen * It can cause acne* Etc.

3. Anticonvulsants such as topiramate a. Anticonvulsants or anti seizure are medication used to treat epileptic seizures, bipolar disorder as mood stabilizers and neuropathic pain. In the study conducted by Department of Neurology, Canisius Wilhelmina Ziekenhuis, anticonvulsants, considered as a class, reduce migraine frequency by about 1.3 attacks per 28 days compared with placebo, and more than double the number of patients for whom migraine frequency is reduced by > or = 50% relative to placebo.(68)b. Side Effects are not limit to1. The medication may also increase central nervous symptoms such as dizziness, drowsiness, unsteadiness, feeling dull difficulty concentrating, focusing, mood swing, etc.2. The medicine may cause gastrointestinal discomfort such as nausea, and vomiting.3. Other side effects include liver or kidney damage and decrease the amount of platelets in your blood4. Etc.

4. Beta-blocker (usually propranolol [Inderal] or timolol [Blocadren])a. Beta-blocker are also known as beta-adrenergic blocking agents, use to block norepinephrine and epinephrine from binding to beta receptors on nerves to prevent migraine headache. Some researchers suggested that the

addition of combined β blocker plus behavioural migraine management, but not the addition of β blocker alone or behavioural migraine management alone, improved outcomes of optimised acute treatment.(65)b. Side effects are not limit tob.1. Beta-blocker may interact with other medicines, such as thioridazine, chlorpromazine, etc.b.2. Most common side effects include dastrointestional discomfort such as stomach cramps, nausea and vomiting.b.3. The medication may also increase nervous symptoms, including headache, depression, confusion, dizziness, etc.b.4. Etc.

4. Other preventive treatmenta. MethysergideMethysergide interacts with serotonin (5-HT) receptors in treating migraine headache. In the study posted in European Journal of Neuroscience suggested the support of the hypothesis that 5-HT2B receptors located on endothelial cells of meningeal blood vessels trigger migraine headache through the formation of nitric oxide (61), but with certain side effects, including Nausea, vomiting, diarrhea, dizziness, drowsiness, stomach upset, heartburn, etc.

b. Lithium Lithium is a soft, silver-white metal that belongs to the alkali metal group of chemical elements and use to to treat and prevent episodes of mania in people with bipolar disorder. In a review of the use of Lithium treatment of chronic cluster headaches, administered lithium carbonate to two patients whose cluster headaches had brought them to the point of contemplating suicide. Both patients responded quite dramatically. Case 1 has now been virtually free of headaches for over two years and Case 2 has been in remission for over twelve months(62) vut with certain side effects, ivluding restlessness, loss of appetite  stomach pain or bloating, indigestion, weight gain or loss, dry mouth, etc.

c. Intravenous magnesium sulfate The treatment is effective for cluster headache in patient with Low Serum Ionized Magnesium Levels, but some researcher sugested that regardless of the ionized magnesium level. Measurements of ionized magnesium may prove useful in elucidating the pathogenesis of cluster headache and in identifying patients who may benefit from treatment with magnesium.(63).

Intravenous magnesium sulfate  may not suitable to Patient with kidney disease.

d. MelatoninIn a study conducted by Thomas Jefferson University Hospital, reported that a lack of melatonin secretion may predispose the cluster sufferer to nocturnal and, possibly, daytime attacks. Leone et al. demonstrated that melatonin could rapidly alleviate cluster attacks, but only in episodic cluster patients. We report two chronic cluster headache patients who had both daytime and nocturnal attacks that were alleviated with melatonin.(64)

A.3.2. Medication to relieve symptoms during an attackDepending to the severity of the disease, acute attacks may be best prescribed by a prescription version of an NSAID, of which have a potent vasoconstricting action (constricting blood vessels) and patients are instructed to take them during or at the onset of a cluster headache. including1. Triptana. Triptan are a family of tryptamine-based drugs used in the treatment of migraine headache and cluster headache. In the comparison of subcutaneous sumatriptan and oral administration formulation, subcutaneous formulation has a faster time of onset and high rate of efficacy when compared with the oral formulation, but the oral formulation appears to be better tolerated.(67)b. Side effects of Triptan are not limit tob.1. Nauseab.2. Dry mouthb.3. Tinglingb.4. Burning,b.5. Dizzinessb.6. Drowsinessb.7. Warm or cold sensationsb.8. Feelings of heaviness, pressure, or tightnessb. Other severe symptoms include coronary spasm, heart disease, shortness of breath, changes in vision, etc.

2. Ergotamine Ergotamine has been used to treat migraine for a century and is still considered to be the most effective therapeutic agent for acute attacks andt good responses of the medication are associated with plasma concentrations of 0.2 ng/ml or above within one hour of administration.In the same study, researchers also emphasized the principal adverse effects

of ergotamine include nausea, vomiting, weakness, muscle pains, paraesthesiae and coldness of the extremities and suggested dosage must therefore be limited to no more than 10mg per week to minimise toxicity.(66)

3. Etc.

B. In herbal medicine  1. PeppermintPeppermint contains high amounts of menthol which have long been used in herbal medicine to treat various pain conditions including headache. In a randomised, triple-blind, placebo-controlled, crossed-over study conducted in the neurology Clinic of Nemazee Hospital, affiliated with Shiraz University of Medical Sciences, Shiraz, southern Iran, from March 2007 to March 2008. Menthol solution can be an efficacious, safe and tolerable therapeutic option for the abortive treatment of migraine(69)

2. FeverfewFeverfew and it's ingredient parthenolide have shown the inhibition of the brain chemicals that dilate blood vessels and cause a migraine. Some researchers suggested that a CO(2)-extract of feverfew decreased the migraine frequency from 4.76 by 1.9 attacks per month in the MIG-99 group and by 1.3 attacks in the placebo group (P = 0.0456). Logistic regression of responder rates showed an odds ratio of 3.4 in favour of MIG-99 (P = 0.0049). Adverse events possibly related to study medication were 9/107 (8.4%) with MIG-99 and 11/108 (10.2%) with placebo (P = 0.654). MIG-99 is effective and shows a favourable benefit-risk ratio.(G.2) while others insisted that there are insufficient evidence from randomised, double-blind trials to suggest an effect of feverfew over and above placebo for preventing migraine.(70)

3. ButterburButterbur is a creeping underground plant, genus Petasites of 15 -20 species, belonging to the family Asteraceae, native to Northern Hemisphere. In a comparison in a three-arm, parallel-group, randomized trial comparing Petasites extract 75 mg bid, Petasites extract 50 mg bid, or placebo bid in 245 patients with migraine conducted by Albert Einstein College of Medicine, Petasites extract 75 mg bid is more effective than placebo and is well tolerated as a preventive therapy for migraine.(71)

4. Ginkgo bilobaGinkgo biloba is oldest living tree species, genus Ginkgo, belonging to the family Gink-goaceae, native to China. Some researchers suggested that Gingkolide B, a herbal constituent extract from Ginkgo biloba tree leaves, seems to be effective as preventive treatment in reducing migraine attack frequency and in attenuating the use of symptomatic medication in our small series of children with primary headache in a small sample of 30 young patients(G.5). Other found that Ginkgolide B is effective in reducing MA frequency and duration. The effect is clearly evident in the first bimester of treatment and is further enhanced during the second(72)

5. CannabisCannabis is a herbal plant with three putative varieties Cannabis sativa, Cannabis indica and Cannabis ruderalis, native to Central Asia, and South Asia. clinical cannabis indicated that Migraine has numerous relationships to endocannabinoid function. Anandamide (AEA) potentiates 5-HT1A and inhibits 5-HT2A receptors supporting therapeutic efficacy in acute and preventive migraine treatment. Cannabinoids also demonstrate dopamine-blocking and anti-inflammatory effects. AEA is tonically active in the periaqueductal gray matter, a migraine generator and suggested that Migraine, fibromyalgia, IBS and related conditions display common clinical, biochemical and pathophysiological patterns share an underlying clinical endocannabinoid deficiency that may be suitably treated with cannabinoid medicines(73)

6. LavenderHerbalist suggested that rubbing a little lavender oil on your temples, or dropping some in the bath water can be extremely soothing. For the migraine associated with depression or poor digestion, it may be result of the relaxation and coronary circulative effects of the oil(74)

7. OthersMany herbs such a Fenugreek, Black willow, Marjoram, St. John's wort, fennel or caraway seed tea has been used to relieve pain or symptoms of migraines, but they are not mention here because lack of studies.

For information of The World Most Popular Herbs - Health Benefits and Side Effects, visithttp://theworldmostpopularherbs.blogspot.ca/2011/10/world-most-

popular-herbs-health.html

X. In Traditional Chinese Medicine(TCM)A. According to Flaws & Sionneau, 2001,p.346; Yin & Liu, 2000, p.370; Blackwell, 1991 Migraine Headache is as a condition of tou feng (Wind in the head) or pian tou tong(pain in one half of the head), and is mainly due to emotional factors causes of Liver Yang hyperactivity and sometimes may be influenced by exterior Wind-Cold factors, common cold and allergy(H.A.). In the report the author indicated that differetiation of the MH depending to the patient’s pathology and the pathodynamics underlying any particular clinical case is likely to be complex. As pain is the single most important clinical feature, Blood stasis should beaddressed in all cases. Thus, one of the formulas described under thesubheading of Blood Stasis will be included in all acute stage treatments. In addition, Interior Wind is also a common feature and this often occurs due to Liver Fire or stagnant Heat in the Liver. In some cases there is also Phlegm,which binds with Wind to exacerbate the symptoms.(Part 2MIGRAINE HEADACHE IN TCM)

B. Migraine headache caused by Liver Yang rising with Interior Wind1. Symptomsa Visual disturbanceb. Dizzinessc. Irritabilityd. Red tonguee. Wiry pulsef. Etc.

2. Formula Liver Yang rising with Interior Wind - Tian Ma Gou Teng Yin a. Gastrodia and Uncaria formula has been used in TCM for hundred of years to treat the symptoms of headache and migraine as a result of ascendant Liver Yang with internal movement of Wind, caused by Liver and Kidney Yin deficiency and exuberant Liver Yang. This formula is best used during the early stages of a Migraine and combines well with Corydalis H for a strong, double strike against Migraine pain.

b. The ingredients includingb.1. Tian Ma (Rhizoma gastrodiae elatae)b.2. Gou Teng (Ramulus cum uncis uncariae)b.3. Shi Jue Ming (Concha haliotidis)b.4. Zhi Zi (Fructus gardeniae jasminoidis)

b.5. Huang Qin (Radix scutellariae baicalensis)b.6. Yi Mu Cao (Herba leonuri heterophylli)b.7. Chuan Niu Xi (Radix cyathulae officinalis)b.8. Du Zhong (Cortex eucommiae ulmoidis)b.9. Sang Ji Sheng (Ramulus sangjusheng)b.10. Ye Jiao Teng (Caulis polygoni multiflori)b.11. Fu-shen (Sclerotium poriae cocos pararadicis)

C. Liver Fire1. Symptomsa. Red face and eyesb. bitter taste in the mouthc. thirstd. dark and scanty urinee. constipation with dry stoolsf. red tongue with a yellow coatg. rapid pulse

b. Formula Long Dan Xie Gan TangThe formula Long Dan Xie Gan Tang has been used in TCM to treat pain in the hypochondriac region, headache, dizziness, red sore eyes, trouble with hearing, ear swelling or infection, traveling the Liver and Gallbladder meridians to relieve liver heat and fireb.1. Long dan cao (Radix gentianae longdancao)b.2. Huang qin (Radix scutellariae)b.3. Shan zhi zi (Fructus gardeniae jasminoidis)b.4. Ze xie (Caulis mutong)b.5. Mu tong (Semen plantaginis) b.6. Che qian zi (Rhizoma alismatis orientalis)b.7. Chai hu (Radix bupleuri)b.9. Sheng di huang (Radix rehmanniae glutinosae)b.10. Gan cao (radix glycyrrhizae uralensis)b.11. Dang qui (Radix angelicae sinensis)Author note the formula may damage the Kidney due to the presence of Herb Mu Tong

D. Liver qi stagnation1. Symptomsa. Chest distentionb. Hypochondriac pain

c. Nausea, vomitingd. Poor appetitee. Diarrheaf. Depressiong. Mood swingf. Normal tongueg. Wiry pulseh. Etc.

2. Formula as a result of Liver Qi deficiency: Xiao Yao San (Bupleurum and Dang-gui Formula)The formula has been used in TCM to treat anxiety, irritability, stress, and depression due to the challenge of a daily life or premenstrual tension, as a result of liver Qi deficiencya. Chai Hu (radix burpleuri)b. Dang Gui (radix angelicae sinensis)c. Bai Shao (radix paeoniae lactiflorae)d. Bai Zhu (rhizome atractylodis macrocephalae)f. Fu Ling (sclerotium poriae cocos)g. Zhi Gan Cao (honey fried radix glycyrrhizae uralensis)

E. Excess syndrome-pattern with Liver Blood stasis: 1. Symptomsa. Palpable masses in the abdomenb. Irregular a/or painful menstruation possible with dark clots,c. purple nails,d. purple lipse. Tongue Purple, possibly w/purple spotsf. Wiry pulse

b. Formula for Excess syndrome-pattern with Liver Blood stasis: Chai Hu Shu Gan TangThe formula has been used in TCM to treat sighing and flank pain due to emotional stress or premenstrual tension, headache as a result liver Blood stasis.a. Chai hu (Radix Bupleuri Chinensis)b. Chen pi (Pericarpium Citri Reticulatae)c. Bai shao (Radix Paeoniae Lactiflorae)d. Zhi ke (Fructus Aurantii)f. Chuan xiong (Rhizoma Ligustici Chuanxiong)

g. Xiang fu (Rhizoma Cyperi Rotundi)h. Gan cao (Radix Glycyrrhizae Uralensis)

F. Headache Migraine caused by Wind Phlegm1. Symptomsa. Excessive sputumb. Nausea,c. Fullness of the chest and/or epigastriumd. Greasy tongue coate. Etc.

2. Wind Phlegm With Heat (if tongue is red tongue with a yellow coat): Wen Dan Tang (Bamboo & Hoelen Formula)The formula has been used in TCM to treat disharmony between the gallbladder and stomach causes of Qi is blocked in flow transformed phlegm and form of rebellion Qi in the stomach that lead to fear, restlessness, dreaminess and anxietya. Zhi Ban Xia (Rhizoma Pinelliae Ternatae)b. Zhu Ru (Caulis Bambusae In Taeniis)c. Chen Pi (Pericarpium Citri Reticulatae)d. Fu Ling (Poriae Cocos)f. Lian Qiao (Fructus Forsythiae Suspensae)g. Jin Yin Hua (Flos Lonicerae Japonicae)h. Yu Jin (Radix Curcumae)i. Zhi Shi (Fructus Aurantii Immaturus)

3. Formula Wind Phlegm With Cold (if tongue is pale with a white coat): Er Chen Wan (Citrus & Pinellia Combination), ingredients includeThe Formula has been used in TCM to treat nausea and abdominal fullness, dizziness and vertigo, etc., as a result of Withe Phlegm with cold causes of phlegm accumulation, spleen-damp, rebellion qi and unharmonization of the center. a. Chen Pi (Pericarpium Citri Reticulatae)b. Ban Xia (Rhizoma Pinelliae)c. Fu Ling (Poriae Cocos)d. Gan Cao Glycyrrhiza (Radix Glycyrrhizae Uralensis)f. Sheng Jiang Zingiberis (Rhizoma Zingiberis)

G. Blood Stasis1. Symptoms

a. Fixed pain,b. Palpitationc. Pulse appears tense and fastd. Tongue is purple -f. bluish-purple

2. Formula for migraine headache caused by blood stasisTao Hong Si Wu Wan (Persica, Carthamus & Dang-gui Combination)The formula has been used in TCM to treat heavy bleeding of dark, purplish, sticky menstrual blood  sharp and fixed abdominal pain before or during the menses, dizziness, dull headache, etc. as a result of blood stasisa. Shu di huang (Rehmannia glutinosa root-prep)b. Dang gui (Angelica sinensis root)c. Bai shao (Paeonia lactiflora root)d. Tao ren (Prunus persica seed)e. Hong hua (Carthamus tinctorius flower)f. Chuan xiong (Ligusticum wallichii rhizome)

H. Invasion by Exterior Wind Cold1. Symptomsa. Generalized body achesb. Aversion to coldc. Chillsd. Mild fevere. Nasal congestionf. Thin white coatg. Floating, possibly a little tight

2. Formula for mihraine headache caused by Invasion by Exterior Wind Cold: Chuan Xiong Cha Tiao Wan (Ligusticum & Tea Formula)The formula has been used in TCM to treat headache, migraine, or headache on the top, aversion to cold and fever, dizziness, nasal obstruction as a result of Exterior Wind Colda. Bo he (Herba Menthae Haplocalycis)b. Chuan xiong (Rhizoma Ligustici Chuanxiong)c. Jing jie (Herba Schizonepetae Tenuifoliae)d. Qiang huo (Rhizoma Seu Radix Notopterygii)e. Bai zhi (Radix Angelicae Dahuricae)f. Gan cao (Radix Glycyrrhizae Uralensis)g. Fang feng (Radix Saposhnikoviae Divaricatae)

For more information of Chinese herb in Western view, please visit http://chineseherbsinnutrientsperspective.blogspot.ca/2011/10/chinese-herbs-in-western-view-health.html

Migraine & Headache Solution!At Last A Migraine Treatment ThatCan Cure Headaches FAST And For Good?

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