Cluster headache - Aetiology, diagnosis and management

Cluster headache is characterised by repeated attacks of strictly unilateral pain in the orbital region associated with local autonomic symptoms or signs. The attacks are brief but of a very severe, almost excruciating intensity. For unknown reasons males are affected more often than females. Recent studies suggest that an autosomal dominant gene has a role in some families with cluster headache. Hormonal studies indicate a dysfunction in the central nervous system. Neuro-imaging has revealed primary defects in the hypothalamic grey matter. Local homolateral dilatation in the intracranial segment of the internal carotid and ophthalmic arteries during attacks is the result of a generic neurovascular activation, probably mediated by trigeminal parasympathetic reflexes. Sumatriptan 6mg subcutaneously is the drug of choice in the treatment of acute attacks. Inhalation of 100% oxygen can also be recommended. In the prophylactic treatment, verapamil is the first option. Other drugs that can be considered are corticosteroids, which may induce a remission of frequent, severe attacks, and lithium. Oral ergotamine tartrate may be sufficient for patients with night attacks and/or short, rather mild to moderately severe cluster headache periods. Third line drugs are serotonin inhibitors (methysergide and pizotifen) and valproic acid. Patients should he encouraged to keep headache diaries and be carefully instructed about the nature and treatment of the headaches. Alcohol can bring on extra attacks and should not be consumed during active periods of cluster headache

Origins and pathways of cerebrovascular nerves storing substance P and calcitonin gene-related peptide in rat

Origins and pathways of cerebrovascular substance P- and calcitonin gene-related peptide-positive nerves in rat were studied by immunohistochemistry combined with denervation experiments and retrograde axonal tracer technique. The two peptides have been found to coexist in one and the same neuron. After sectioning of the nasociliary nerve bilaterally the substance P/calcitonin gene-related peptide fibers in the rostral half of the circle of Willis and its branches were eliminated, whereas the number decreased in the caudal half of the circle of Willis and rostral two thirds of the basilar artery. Substance P/calcitonin gene-related peptide fibers in the internal carotid arteries, the caudal third of the basilar artery and the vertebral arteries were not affected by the nerve section. After application of the retrograde axonal tracer True Blue onto the proximal segment of the middle cerebral artery the dye accumulated in several Substance P/calcitonin gene-related peptide-containing cells in the ophthalmic division of the ipsilateral trigeminal ganglion and in a few cells in the maxillary trigeminal division and in the internal carotid miniganglion. No other cranial ganglia accumulating the dye contained any substance P/calcitonin gene-related peptide-positive cells. It is concluded that the rostral portion and part of the caudal portion of the cerebral vessels are innervated by substance P/calcitonin gene-related peptide-containing fibers from the trigeminal ganglion and the internal carotid miniganglion. The great majority of trigeminal fibers reach the vessels via the nasociliary nerve of the ophthalmic division, which enters the cranial cavity through the ethmoidal foramen, whereas fibers from the miniganglion project directly to the bypassing internal carotid artery. A probable pathway for the fibers from the maxillary division is suggested. The caudal portion receives, in addition, a supply from other sensory ganglia (lower cranial and/or upper cervical dorsal root ganglia)

Origins and pathways of cerebrovascular vasoactive intestinal polypeptide-positive nerves in rat

In order to clarify the origins and pathways of vasoactive intestinal polypeptide (VIP)-containing nerve fibers in cerebral blood vessels of rat, denervation experiments and retrograde axonal tracing methods (true blue) were used. Numerous VIP-positive nerve cells were recognized in the sphenopalatine ganglion and in a mini-ganglion (internal carotid mini-ganglion) located on the internal carotid artery in the carotid canal, where the parasympathetic greater superficial petrosal nerve is joined by the sympathetic fibers from the internal carotid nerve, to form the Vidian nerve. VIP fiber bridges in the greater deep petrosal nerve and the internal carotid nerve reached the wall of the internal carotid artery. Two weeks after bilateral removal of the sphenopalatine ganglion or sectioning of the structures in the ethmoidal foramen, VIP fibers in the anterior part of the circle of Willis completely disappeared. Very few remained in the middle cerebral artery, the posterior cerebral artery, and rostral two-thirds of the basilar artery, whereas they remained in the caudal one-third of the basilar artery, the vertebral artery, and intracranial and carotid canal segments of the internal carotid artery. One week after application of true blue to the middle cerebral artery, dye accumulated in the ganglion cells in the sphenopalatine, otic and internal carotid mini-ganglion; some of the cells were positive for VIP. The results show that the VIP nerves in rat cerebral blood vessels originate: (a) in the sphenopalatine, and otic ganglion to innervate the circle of Willis and its branches from anterior and caudally and (b) from the internal carotid mini-ganglion to innervate the internal carotid artery at the level of the carotid canal and to some extent its intracranial extensions

Dynorphin B is present in sensory and parasympathetic nerves innervating pial arteries

Dynorphin B (dyn B) in trigeminal ganglion cells and in perivascular nerve fibers in pial arteries was demonstrated in rat, guinea-pig, and monkey by immunohistochemistry. The pathway from the trigeminal ganglion, which runs via the nasociliary nerve and ethmoidal foramen to the pial arteries, was shown in rat by retrograde tracer technique and nerve section. In the guinea-pig the peptide was demonstrated to coexist with substance P and calcitonin gene-related peptide in neurons of the trigeminal ganglion and pial nerve fibers, i.e., it was present in cerebrovascular sensory nerves with primarily nociceptive function. Another finding in guinea-pig was a coexistence of dyn B with vasoactive intestinal polypeptide in the pial nerve fibers and neurons of the sphenopalatine ganglion, indicating a presence also in parasympathetic nerves to the cerebral vessels. No vasomotor effect of dyn B could be detected in isolated segments of rat pial arteries, which rules out a direct postsynaptic effect on vascular tone. The peptide did not display a prejunctional modulatory action on the adrenergic nerves present in the vessels. The function of dyn B in the cerebrovascular nerves is discussed

Trigeminal fibre collaterals storing substance P and calcitonin gene-related peptide associate with ganglion cells containing choline acetyltransferase and vasoactive intestinal polypeptide in the sphenopalatine ganglion of the rat. An axon reflex modulating parasympathetic ganglionic activity?

In immunohistochemical studies on rat two types of nerve fibres, both showing substance P and calcitonin gene-related peptide-like immunoreactivity, have been localized in the sphenopalatine ganglion, the principal cells of which contain both vasoactive intestinal polypeptide and choline acetyltransferase. One fine-calibre fibre type forms basket-like arrangements around approximately 3-5% of the principal neurons, whereas another, more coarse type traverses the ganglion without making contacts with the ganglion cells. By transection of nerves connecting with the ganglion, in combination with retrograde tracing experiments, it was concluded that the fine-calibre fibres exclusively come from the trigeminal ganglion, whereas the second type in addition, and mainly, originate in the internal carotid ganglion which is situated along the greater superficial petrosal nerve and the pterygoid nerve at their junction with the internal carotid nerve. The brain vasculature was shown to be one target structure for the innervated principal cells in the sphenopalatine ganglion. The arrangement provides the functional possibility for a modulatory interaction between the autonomic and sensory systems, thus resembling an axon reflex mechanism in the peripheral nervous system

Neonatal chronic sympathectomy in normotensive rats affects pial arteries: enhanced stiffness and reduced capacity to dilate

The functional implication of previously shown effects on pial wall morphology by sympathectomy was tested. Following either ganglionic or pre-ganglionic denervation in 1-week-old rats the passive arterial compliance was reduced in basal cerebral arteries of 20-week-old normotensive, but not of hypertensive animals. The magnitude of the denervation induced stiffness was similar to the alteration seen in spontaneously hypertensive rats when compared with normotensive animals. No difference was seen between the two types of denervation. Following ganglionic sympathectomy in 1-week old normotensive rats-and examined 19 weeks later-the increase in cerebral blood flow (measured with the [14C]butanol sampling technique) induced by high arterial CO2 concentration was attenuated compared with control, whereas basal cerebral blood flow of 20-week-old animals was not different from control. The results indicate a long-term role by the sympathetic nerves not only on vessel wall composition, but also on the regulatory capacity of the cerebral circulation

Origins and pathways of choline acetyltransferase-positive parasympathetic nerve fibers to cerebral vessels in rat

The presence of cholinergic nerve fibers in the brain vasculature has been a matter of controversy, partly due to the lack of a reliable histochemical marker. Accordingly, no distinct information about the origin and pathways for such fibers has been available. In the present study on the rat pial vasculature, utilizing a choline acetyltransferase (ChAT) antibody, which is able to demonstrate this enzyme in peripheral nervous tissue, evidence was obtained for an innervation by cholinergic fibers of large pial arteries. Vasoactive intestinal polypeptide (VIP) was present in or in close association with these fibers. By the aid of the retrograde axonal tracer True Blue (TB) applied to the middle cerebral arterial wall, such fibers were shown to originate in a subgroup of ChAT-positive cells in the sphenopalatine, otic, and internal carotid ganglia, which, in addition, contained VIP. The ChAT-positive pial nerve fibers were few in relation to the VIP-immunoreactive fibers, as was also illustrated by the few TB-positive cells in the ganglia that were ChAT positive as compared with the number of cells that were VIP positive. Only a small population of ChAT-containing neurons in these ganglia appeared to project to the pial vessels. The pathway from the sphenopalatine ganglion is via a membranous structure on the medial orbital wall, through the ethmoidal foramen, and along the internal ethmoidal artery to reach the circle of Willis. The fibers from the internal carotid and otic ganglia probably bridge to the internal carotid artery in the carotid canal, those from the otic ganglion after an initial course in the lesser superficial petrosal nerve

Characterization of dilatation induced by electrical field stimulation in mammalian cerebral and peripheral vessels

The ability of electrical field stimulation in releasing transmitter from isolated blood vessels in vitro, during recordings of constrictor or dilator responses, is dependent upon an appropriate choice of stimulation parameters which avoid concomitant change in tone due to a direct effect on the vascular smooth muscle membrane. In many species, including man, small arteries such as pial arteries frequently respond to electrical field stimulation with a dilatation which is TTX-resistant. Such dilatations occur even with stimulus parameters of 7·5 V/60 mA at 0·1 ms, 6 Hz. The stimulation parameters required to induce the TTX-resistant response are just above those needed to obtain a purely neurogenic contractile or dilatory response in vessels equipped with a dense net of adrenergic nerves, such as rabbit central ear artery, and, in addition, highly sensitive postsynaptic agr- or beta-adrenergic receptors, such as the buccal segment of the facial vein. This prompted us to characterize further the nature of the response. It was tested whether the relaxation, despite being TTX-resistant, might be neurogenic in origin. 4-Aminopyridine, in doses that usually enhance the transmitter release from nerves, did not affect the response. Blockade by a variety of dilator antagonists, the presence of excess amounts of known dilators or removal or emptying of known vasodilator nerves did not inhibit the response. Removal of extracellular calcium did not abolish the response. Therefore, it is highly unlikely that neuronal release is involved to any measurable extent in this response. The relaxation was not significantly affected by removal of endothelium, blockade of endothelium-derived relaxing factor, or interference with mast cells. At modest stimulatory parameters (12-13 V/96-104 mA at 0·1 ms, 7-8 V/56-64 mA at 0·3 ms, at 6 Hz) chlorine gas bubbles could be seen forming at the electrode or mounting hook; this gas is toxic to the musculature and relaxes a pre-contracted vessel. At stronger stimulation (rang 12 V/96 mA, rang 0·3 ms at 6 Hz) a relaxation supervened that was almost prevented by scavengers of oxygen free-radical metabolites. This relaxation was partly irreversible, indicating damage to the contractile elements. We conclude that when studying electrically induced release of vasodilator transmitters in vessels not equipped with an highly effective transmitter/receptor function, even a small rise in stimulatory parameters - in order to enhance transmitter release - causes relaxations that are non-neurogenic. At these and higher parameters the electrical field starts generating chlorine gas, as well as free radicals, which causes relaxation of the vessels. Therefore, stimulation at supramaximal voltage, commonly utilized in such studies to assure an effective neuronal activation, is not suitable when changes in vascular tone are used as a parameter

Origins of substance P- and calcitonin gene-related peptide-containing nerves in the internal carotid artery of rat

An aggregation of substance P (SP)- and calcitonin gene-related peptide (CGRP)-containing nerve cells (internal carotid mini-ganglion) is described at the junction between the greater superficial petrosal nerve and the internal carotid nerve close to the internal carotid artery. A retrograde tracer dye technique demonstrates that this ganglion and the trigeminal and superior vagal ganglia supply the internal carotid artery with SP/CGRP fibers at, above and below this level, respectively. Implications of this finding for cranial painful syndromes in man are discussed

Galanin-positive nerves of trigeminal origin innervate rat cerebral vessels

(GAL)-positive nerve fibers in rat cerebral vessels were demonstrated by immunohistochemistry, and their origin in the trigeminal ganglia and pathway in the nasociliary nerve to the vessels was shown by retrograde tracer technique and nerve transection. Some fibres in the vertebrobasilar system appear to originate in extracranial sources. With the antiserum used only few GAL fibers could be seen in the vessels, mostly in the vertebrobasilar system. In neonatally sympathectomized animals a rich network could be visualized in most pial arteries - still particularly in the vertebrobasilar system - probably as a result of a diminished competition for nerve growth factor. No vasomotor effect of GAL could be detected in isolated segments of pial arteries, neither in normal nor in sympathectomized animals, which rules out a direct postsynaptic effect on vascular tone. GAL did not display prejunctional modulatory action on the adrenergic nerves present in the vascular preparations. A sensory function of GAL is discussed