Cluster Headache: What's New?

BACKGROUND: Cluster headache is a highly disabling primary headache disorder which is widely described as the most painful condition a human can experience. AIM: To provide an overview of the clinical characteristics, epidemiology, risk factors, differential diagnosis, pathophysiology and treatment options of cluster headache, with a focus on recent developments in the field. METHODS: Structured review of the literature on cluster headache. RESULTS: Cluster headache affects approximately one in 1000 of the population. It is characterised by attacks of severe unilateral head pain associated with ipsilateral cranial autonomic symptoms, and the tendency for attacks to occur with circadian and circannual periodicity. The pathophysiology of cluster headache and other primary headache disorders has recently become better understood and is thought to involve the hypothalamus and trigeminovascular system. There is good quality evidence for acute treatment of attacks with parenteral triptans and high flow oxygen; preventive treatment with verapamil; and transitional treatment with oral corticosteroids or greater occipital nerve injection. New pharmacological and neuromodulation therapies have recently been developed. CONCLUSION: Cluster headache causes distinctive symptoms, which once they are recognised can usually be managed with a variety of established treatments. Recent pathophysiological understanding has led to the development of newer pharmacological and neuromodulation therapies, which may soon become established in clinical practice

OnabotulinumtoxinA in Migraine: A Review of the Literature and Factors Associated with Efficacy

The efficacy of onabotulinumtoxinA (OnaB-A) as a preventative treatment for chronic migraine, emerging fortuitously from clinical observation is now supported by class one evidence and over two decades of real-world clinical data. There is still limited ability to predict a clinically meaningful response to OnaB-A for individual patients, however. This review summarises briefly the proposed mechanism of OnaB-A in chronic migraine, the literature of predictors of clinical response, and recent developments in the field

Treatment of SUNCT/SUNA, Paroxysmal Hemicrania, and Hemicrania Continua: An Update Including Single-Arm Meta-analyses

Purpose of Review: This review presents a critical appraisal of the treatment strategies for short-lasting unilateral neuralgiform headache attacks (SUNHA), paroxysmal hemicrania (PH), and hemicrania continua (HC). We assess the available, though sparse, evidence on both medical and surgical treatments. In addition, we present estimated pooled analyses of the most common treatments and emphasize recent promising findings. / Recent Findings: The majority of literature available on the treatment of these rare trigeminal autonomic cephalalgias are small open-label observational studies and case reports. Pooled analyses reveal that lamotrigine for SUNHA and indomethacin for PH and HC are the preventative treatments of choice. Second-line choices include topiramate, gabapentin, and carbamazepine for SUNHA; verapamil for PH; and cyclooxygenase-2 inhibitors and gabapentin for HC. Parenteral lidocaine is highly effective as a transitional treatment for SUNHA. Novel therapeutic strategies such as non-invasive neurostimulation, targeted nerve and ganglion blockades, and invasive neurostimulation, including implanted occipital nerve stimulators and deep brain stimulation, appears to be promising options. / Summary: At present, lamotrigine as a prophylactic and parenteral lidocaine as transitional treatment remain the therapies of choice for SUNHA. While, by definition, both PH and CH respond exquisitely to indomethacin, evidence for other prophylactics is less convincing. Evidence for the novel emerging therapies is limited, though promising

Treatment of SUNCT/SUNA, Paroxysmal Hemicrania, and Hemicrania Continua: An Update Including Single-Arm Meta-analyses

Purpose of Review: This review presents a critical appraisal of the treatment strategies for short-lasting unilateral neuralgiform headache attacks (SUNHA), paroxysmal hemicrania (PH), and hemicrania continua (HC). We assess the available, though sparse, evidence on both medical and surgical treatments. In addition, we present estimated pooled analyses of the most common treatments and emphasize recent promising findings. / Recent Findings: The majority of literature available on the treatment of these rare trigeminal autonomic cephalalgias are small open-label observational studies and case reports. Pooled analyses reveal that lamotrigine for SUNHA and indomethacin for PH and HC are the preventative treatments of choice. Second-line choices include topiramate, gabapentin, and carbamazepine for SUNHA; verapamil for PH; and cyclooxygenase-2 inhibitors and gabapentin for HC. Parenteral lidocaine is highly effective as a transitional treatment for SUNHA. Novel therapeutic strategies such as non-invasive neurostimulation, targeted nerve and ganglion blockades, and invasive neurostimulation, including implanted occipital nerve stimulators and deep brain stimulation, appears to be promising options. / Summary: At present, lamotrigine as a prophylactic and parenteral lidocaine as transitional treatment remain the therapies of choice for SUNHA. While, by definition, both PH and CH respond exquisitely to indomethacin, evidence for other prophylactics is less convincing. Evidence for the novel emerging therapies is limited, though promising

Long-term follow up of intractable chronic short lasting unilateral neuralgiform headache disorders treated with occipital nerve stimulation

BACKGROUND: Occipital nerve stimulation is a potential treatment option for medically intractable short-lasting unilateral neuralgiform headache attacks. We present long-term outcomes in 31 patients with short-lasting unilateral neuralgiform headache attacks treated with occipital nerve stimulation in an uncontrolled open-label prospective study. METHODS: Thirty-one patients with intractable short-lasting unilateral neuralgiform headache attacks were treated with bilateral occipital nerve stimulation from 2007 to 2015. Data on attack characteristics, quality of life, disability and adverse events were collected. Primary endpoint was change in mean daily attack frequency at final follow-up. RESULTS: At a mean follow-up of 44.9 months (range 13-89) there was a 69% improvement in attack frequency with a response rate (defined as at least a 50% improvement in daily attack frequency) of 77%. Attack severity reduced by 4.7 points on the verbal rating scale and attack duration by a mean of 64%. Improvements were seen in headache-related disability and depression. Adverse event rates were favorable, with no electrode migration or erosion reported. CONCLUSION: Occipital nerve stimulation appears to offer a safe and efficacious treatment for refractory short-lasting unilateral neuralgiform headache attacks with significant improvements sustained in the long term. The procedure has a low adverse event rate when conducted in highly specialised units

Evolution of Surface Nanopores in Pressurised Gyrospun Polymeric Microfibers

The selection of a solvent or solvent system and the ensuing polymer–solvent interactions are crucial factors affecting the preparation of fibers with multiple morphologies. A range of poly(methylmethacrylate) fibers were prepared by pressurised gyration using acetone, chloroform, N,N-dimethylformamide (DMF), ethyl acetate and dichloromethane as solvents. It was found that microscale fibers with surface nanopores were formed when using chloroform, ethyl acetate and dichloromethane and poreless fibers were formed when using acetone and DMF as the solvent. These observations are explained on the basis of the physical properties of the solvents and mechanisms of pore formation. The formation of porous fibers is caused by many solvent properties such as volatility, solubility parameters, vapour pressure and surface tension. Cross-sectional images show that the nanopores are only on the surface of the fibers and they were not inter-connected. Further, the results show that fibers with desired nanopores (40–400 nm) can be prepared by carefully selecting the solvent and applied pressure in the gyration process

OnabotulinumtoxinA for hemicrania continua: open label experience in 9 patients

BACKGROUND: Hemicrania continua is a strictly unilateral, continuous headache, typically mild to moderate in severity, with severe exacerbations commonly accompanied by cranial autonomic features and migrainous symptoms. It is exquisitely responsive to Indomethacin. However, some patients cannot tolerate treatment, often due to gastrointestinal side effects. Therapeutic alternatives are limited and controlled evidence lacking. METHODS: We present our experience of nine patients treated with OnabotulinumtoxinA for hemicrania continua. All patients were injected using the PREEMPT (Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy) protocol for migraine. RESULTS: Five of nine patients demonstrated a 50% or more reduction in moderate to severe headache days with OnabotulinumtoxinA with a median reduction in moderate to severe headache days of 80%. Patient estimate of response was 80% or more in five subjects. The median and mean duration of response in the five responders was 11 and 12 weeks (range 6-20 weeks). Improvements were also seen in headache-associated disability CONCLUSIONS: OnabotulinumtoxinA adds a potential option to the limited therapeutic alternatives available in hemicrania continua

The Hy-MASS concept : Hydrothermal microwave assisted selective scissoring of cellulose for: In situ production of (meso)porous nanocellulose fibrils and crystals

The hydrothermal microwave-assisted selective scissoring (Hy-MASS) of depectinated orange peel residues (OPR), produced via conventional acid hydrolysis and acid-free microwave processing, to yield (meso)porous nanocellulose fibrils and crystals simultaneously in the absence of additional auxiliary reagents and/or mechanical treatment is reported. In the stepwise microwave hydrothermal treatment (MHT) of OPR from 120 °C-200 °C at 20 °C intervals, release of residual pectins and hemicelluloses is observed up to 180 °C producing nanocellulose fibrils (3-15 × 500-2000 nm). Beyond 180 °C, selective leaching/hydrolysis of amorphous regions occur to yield nanocellulose crystals (200-400 × 40-50 nm) and crystallites (5-15 × 40-50 nm). This selective, step-wise scissoring process is termed Hy-MASS Concept. Structure, morphology and properties of (meso)porous nanocellulose are strongly influenced by pectin extraction methodology employed. With acid depectinated OPR, deconstruction of the lignocellulosic matrix via microwave is hastened by approx. 20 °C with respect to acid-free microwave depectinated OPR. Td of acid depectinated nanocelluloses (CMC) is ca. 350 °C compared to microwave depectinated nanocelluloses (MMC, Td, varies 342-361 °C). Nanocellulose produced via microwave pre-treatment is (meso)porous: BJH pore size 5-35 nm; BET surface area, 1.5-107 m2 g-1, and; BJH pore volume, 0.01-0.27 cm3 g-1, when compared to acid pre-treated counterparts. The crystallinity index of CMC and MMC increases in two stages, 120-140 °C (ca. 8%) and at 180-200 °C (5-9%). XRD revealed presence of calciuim salts, most likely calcium oxalate. The hydration capacities of nanocelluloses (12-23 g water per g sample) are much higher than their precursors or literature citrus nanocellulose

Microvascular decompression or neuromodulation in patients with SUNCT and trigeminal neurovascular conflict?

Objectives To assess the effectiveness of neuromodulation and trigeminal microvascular decompression (MVD) in patients with medically-intractable short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Methods Two patients with medically refractory SUNCT underwent MVD following beneficial but incomplete response to neuromodulation (occipital nerve stimulation and deep brain stimulation). MRI confirmed neurovascular conflict with the ipsilateral trigeminal nerve in both patients. Results Although neuromodulation provided significant benefit, it did not deliver complete relief from pain and management required numerous postoperative visits with adjustment of medication and stimulation parameters. Conversely, MVD was successful in eliminating symptoms of SUNCT in both patients with no need for further medical treatment or neuromodulation. Conclusion Neuromodulation requires expensive hardware and lifelong follow-up and maintenance. These case reports highlight that microvascular decompression may be preferable to neuromodulation in the subset of SUNCT patients with ipsilateral neurovascular conflict