Cluster headaches cause more severe pain than any other type of headaches. Some patients even call them suicide headaches because they provoke thoughts of suicide. The name comes from the fact that they occur in clusters – every day for a couple of months and then they go away for a year or longer. In those with chronic cluster headaches they never go away. The headaches are brief – anywhere from 30 minutes to 3 hours. They are always one-sided, with pain usually around the eye, and are accompanied by tearing, nasal congestion, and sometimes restlessness. More men than women suffer from them.
Treatment of cluster headaches can be very effective. A 10-day course of prednisone or an occipital nerve block can abort the entire cluster. We also have preventive drugs, such as a blood pressure medicine, verapamil (used in high doses), epilepsy drugs, and lithium. These are taken daily to prevent headaches. To treat individual attacks, inhalation of 100% oxygen under high flow, zolmitriptan nasal spray (Zomig NS), and sumatriptan (Imitrex) injections can be true life savers.
Some of the alternative therapies that have been reported to help include melatonin, intranasal capsaicin (hot pepper extract), and an herbal product, Boswellia (Nature’s Way is a good brand for herbals).
Unfortunately, there are some cluster headache sufferers who do not respond to any of these treatments. We even treated some patients with intravenous histamine, which requires hospital admission and two of my patients were implanted with a vagus nerve stimulator (with good relief).
Some cluster patients have been found to have low testosterone levels and treating them with testosterone seems to help.
This testosterone connection led to trials of a fertility drug, clomiphene citrate (Clomid). Clomiphene enhances testosterone production and binds to hypothalamic estrogen receptors, which is why it was considered as a treatment for cluster headaches. A second case of successful treatment of cluster headaches with Clomid has just appeared in the journal Headache. This was a case of a 65-year-old man with a 17-year history of chronic cluster headaches who did not respond or had significant side effects to many cluster headache preventive medications including verapamil, lithium, valproic acid, topiramate, baclofen as well as greater occipital nerve blocks and inpatient hospitalization.
The patient experienced 3-5 headaches per day. On Clomid (100 mg/day) he became 100% pain-free and remained so for three and half years with only mild fatigue as a side effect. He then had cluster headache recurrence and did well on gabapentin for another 3 years, but then his headaches returned. Clomiphene was restarted, and he became pain-free once again.
Clomid should be considered when the usual preventive drugs for cluster headaches are ineffective.
