Mercifully rare, cluster headaches score ten out of ten for pain

    Mercifully rare, cluster headaches score ten out of ten for pain

    The world’s worst headaches

    22 October 2015

    ‘When you’re lying awake with a dismal headache/ and repose is taboo’d by anxiety’ sang W.S. Gilbert’s Lord Chancellor in Iolanthe, as ‘love unrequited’ ‘weaves itself into [his] midnight slumbers’. Unrequited love is not high on the list of headache triggers but perhaps it should be. Headaches are as common as their causes and they affect nearly everyone at one time or another. The question is, which ones matter?

    Headaches can be divided into primary and secondary. Primary headaches — including tension-type headaches, migraine, trigeminal neuralgia, cluster headache, paroxysmal hemicrania and hemicrania continua — cannot be diagnosed without excluding a secondary headache. Secondary headaches, or those with an underlying obvious cause, are the serious ones. Systemic symptoms — such as persistent vomiting, weight loss, confusion and memory disturbance, fever, neck stiffness with acute onset, persistent limb or face weakness, unsteadiness, hearing loss, pain with blurred vision in one eye and one-sided temporal headache — are all worrying. Other bad signs are persistent weakness of a part of the body, unsteadiness, occipital (at the back of the head) headache (particularly in children), imbalance and persistent distortion or visual loss. The history of the headache is key to assessing its seriousness. One belonging to a long sequence across years, not days or weeks, is unlikely to be dangerous. On the other hand, if there’s a recent head injury, or the headache comes on when changing position, or after coughing, bending, straining, sneezing or sex, that calls for further investigation. A history of cancer, HIV, lupus or blood clotting disorders also requires special considerations.

    But relax, most headaches are innocent and fleeting. Common primary headaches usually start as episodic events. Very occasionally they progress to chronic headache, affecting the sufferer more days of the month than not. Tension-type headache is usually brief, lasting up to two hours. Treatment should ideally be taking a walk, resting or listening to relaxing music. It is best to avoid tablets — most painkillers take an hour to work and all cause problems if used too frequently.

    Migraine is a disabling headache affecting 15 per cent of people in the UK; 10 per cent of school-age children have migraine. It is believed to be a genetic abnormality and frequently runs in families. The gene makes the brain hypersensitive to change. Females are affected about three times more than males. Probably the hormones!

    The most frequent triggers for a migraine attack in those susceptible are stress, dehydration, missed meals, hormones, particular foods, smells, caffeine, too much sleep, too little sleep and changes in barometric pressure — or unrequited love? However, a trigger isn’t always obvious. Migraine begins with activity in the brain stem. From there, waves of cortical-spreading depression flow over the brain and in about a quarter of people result in aura. Aura, usually visual, may include numbness and tingling of an arm, face and one side of the tongue, word-finding difficulties and mood changes. Then the pain starts. Nausea and vomiting, and dislike of light, noise and smells are frequent accompaniments. Most people need to lie down in a quiet, dark room. After the pain subsides, functional disability sets in for days. The whole series of events — the prodrome (the time leading up to the headache) which may have yawning, lethargy, extra energy or thirst as features, followed by the aura (if present), the pain with associated features and the postdrome — typically lasts between four and 72 hours. It is totally disabling, such that the World Health Organisation classes it as the seventh most disabling condition in the world. Attacks are very variable in frequency, from possibly one a year to more than one a week and in a few there are more days of the month affected than not.


    Usually effective treatments are aspirin, paracetamol, paracetamol/codeine/caffeine combinations (such as Syndol), ibuprofen or a triptan. These medicines were introduced to the UK in 1991 and revolutionised the lives of sufferers like me. All these medicines are for short-term use and should not be used more than six times a month. If migraineurs suffer more attacks than using six days’ treatment per month can treat, most will need preventive medications, which are taken every day to try to reduce the frequency, severity and duration of the attacks.

    Cluster headache is a nasty beast but mercifully far less common, affecting approximately one in a thousand. Men are three times more likely than women to suffer and smoking has been linked to the condition. The headache is strictly unilateral and is usually a ten out of ten pain score. The pain is so severe that it has been associated with suicide. For good measure a red watery eye, runny nose or blocked nose, swelling or eyelid drooping on the side of the headache can be accompaniments. Attacks usually start with agonising pain lasting from 15 minutes to two hours, may occur several times a day and render the person totally unable to think or do anything but moan and be agitated.

    Once identified, this monster can be treated with triptans (by nasal spray or injections), or high-flow oxygen. Preventive drugs can be used to reduce attack frequency. Strangely, attacks generally come in bouts or clusters over several weeks and may then go away completely for months or even years. Two conditions possibly related to cluster headache, paroxysmal hemicrania and hemicrania, respond to an anti-inflammatory drug called Indometacin. There are many types of cluster, some lasting seconds and occurring up to 20 or more times a day.

    Trigeminal neuralgia usually affects the lower part of the face and feels like pulses of shock waves travelling through the face, typically after minor stimulation such as a puff of wind. It is an exceedingly painful condition and notoriously difficult to treat for some people.

    One condition which is widely underdiagnosed and rejected by many headache sufferers is medication-overuse headache. This is most common in people who have progressed from episodic migraine to a more frequent variety, ending in the headache becoming painkiller-dependent. The headache is constant, usually around a five out of ten on the pain score, and people feel they must take the next dose of medication to stop things getting worse. The migraine brain likes stability, and once it recognises a certain level of triptan, paracetamol, codeine or ibuprofen as normal, it will produce pain until the status quo is restored. Needless to say, persuading people with constant headache to stop taking pain-easing medicines is very difficult. Often, stopping them cold-turkey will lead to worsening of headaches and with understandable frustration; the sufferer resumes the painkiller habit.

    Perversely migraine can stimulate brilliant artistic works, as evidenced by known sufferers such as Picasso, Sarah Raphael and Giorgio de Chirico.

    Headaches produce individual and social costs. Many chronic sufferers cannot hold down a job. The country is said to spend some £7 billion a year in the direct (hospital costs, tests, doctors and nurses) and indirect costs of headache. The problem is global, highlighted by the WHO and the worldwide campaign Lifting the Burden. The national societies in the UK are Migraine Action, Migraine Trust, the Trigeminal Neuralgia Society and Ouch (Organisation for Understanding of Cluster Headache), all excellent charities supporting individuals and also lobbying parliamentarians. However, more money needs to be spent to raise awareness among the population of what symptoms are worrying and what treatments are available, and more too on developing and supporting doctors and scientists who treat and research these very frequent, disabling conditions.