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A Nail in the Head: Short-lasting Unilateral Neuralgiform Headache Attacks

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An article with “short-lasting unilateral neuralgiform headache attacks” in the title isn’t necessarily going to catch your attention, but if you’ve experienced this type of headache, you know it’s not something that can be ignored.

Earlier this week we saw a video of Rev. David Wakefield, who has both chronic cluster headache and SUNCT, a form of the headache we’ll be talking about today. If you missed the video, see New Device Approved by FDA to Fight Cluster Headache (video).

SUNCT and SUNAWhat is officially called short-lasting unilateral neuralgiform headache attacks is actually one type of chronic daily headache. The headaches last only seconds or minutes (as long as ten minutes), but they are very painful and hit you at least once a day. The pain is on one side of the head, and the eye on that side will usually get red and watery.

As the title to this article implies, the pain is often described as “stabbing”, like a nail in the head.

With the red eye and tearing, the diagnosis is usually SUNCT, which stands for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. That’s the version that Rev. Wakefield deals with.

If there is tearing (watery eye) or red eye, or neither, the diagnosis may be SUNA, or short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms. These headaches are accompanied by other symptoms that may occur in SUNA or SUNCT, such as congestion, facial sweating, and drooping or swelling or the eyelid.

Because of the congestion and tearing, SUNCT or SUNA may actually be misdiagnosed as sinus headache (more commonly, migraine is misdiagnosed as sinus headache – see Sinus Headache – Did You Really Beat It?).

Technically, the condition is considered “chronic” when it continues for a year or more, with less than a month pain-free.

Treatment of SUNCT and SUNA

There are some treatments that seem to help some people, but there have not been enough clinical trials to come up with consistent solutions (if they exist – treatment may be a very individual thing, especially until our understanding of the condition grows). Because the attacks are so brief, abortive treatment (stopping individual attacks) is not a major focus. Intravenous lidocaine or a phenytoin injection are sometimes used to try to stop a series of attacks.

To prevent attacks, medications such as lamotrigine, carbamazepine, gabapentin, and topiramate seem to help some patients, and nerve blocks may provide temporary relief.

Sometimes a certain cause is found for these symptoms, in which case treatment will vary. For example, compression of the trigeminal nerve or a structural lesion.

For more information, see:

Concussion: What Kind of Rest is Needed?

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A large study is questioning some of the common wisdom regarding treatment of concussion in children.

We’ve talked a lot in the past about concussion (which is a brain injury), especially related to sports injuries. Concussion needs to be taken seriously – it could result in ongoing symptoms. Recent recommendations include being very cautious of activities that could result in another concussion, and getting sufficient rest after the injury.

In particular, cognitive rest. That is, avoiding (for example) reading, homework, and video games. (For more, see the 2014 study Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms)

But while getting rest and avoiding activity with a risk of concussion seems to be the best, does that mean that the child or teen should lie in bed all day? Apparently not.

A study involving 3063 children and teens (up to the age of 18) compared patients who returned to physical activity (within 7 days) with those who were restricted to more “conservative” rest. The question – which group was experiencing more postconcussive symptoms at 28 days?

Postconcussive Symptoms in Children and YouthAs you can see from the chart, those who went back to physical activity within 7 days were significantly less likely to have the unwanted symptoms.

Depending on who you talk to, there seem to be two dangers. First, keeping your child away from any physical activity seems to be a danger. Activity is all the more critical to growing children and teens – it can play an important part in their recovery. But the other danger remains – not taking the concussion seriously, and putting the child right back into the sport that caused the injury in the first place.

A slow and cautious return to low-risk physical activity, with limited brain-work for a while, seems to be the best advice.

For more on the study, see the abstract: Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. Also see Early return to physical activity after concussion may reduce post-concussive symptoms at the New York Headache Clinic.

Cluster Headaches Causes

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As with any type of pain, the agony of this super-intense headache raises the question – what exactly are cluster headaches causes? In other words, why am I in such incredible pain?

Cluster Headaches Causes
Based on this image from Matt Brown
There are actually two questions to ask. First, what may actually trigger a cluster headache attack at a certain time? But the other question is – why is it that a certain trigger results in a headache for one person, but not another? In other words, what is the cause of the disease in the first place?

But before we get into cluster headaches causes, make sure you understand what cluster is. Here is a handy infographic contrasting migraine with cluster: cluster headache vs migraine

So why does one person get cluster headache attacks, while another person doesn’t?

There has been some research done into the possibility of a genetic cause, or at least genetic factors that contribute. For many years now, researchers have recognized that family members of a cluster patient are more likely to have cluster themselves. In late 2016, a study from Italy was published in the Journal of Headache and Pain, indicating some possible genetic variants that seem to increase a patient’s risk (A genome-wide analysis in cluster headache points to neprilysin and PACAP receptor gene variants.).

Most often when we talk about cluster headaches causes, we end up discussing the brain and nervous system. We know, through modern imagine techniques, that the hypothalamus is involved, as has long been suspected. The trigeminal nerve in the head seems to be important, especially in the process that causes symptoms such as eye pain, tears and congestion. Other possible indirect cluster headache causes are related to a nerve cluster behind the nose (the sphenopalatine ganglion), histamine, and the blood vessels themselves. Read more about these factors here: What is behind the dreaded Cluster Headache?

All that being said, there is still nothing we can point to with certainty. Cluster may indeed be caused by a number of factors working together – for example, even someone who is predisposed genetically may not get cluster because other physical factors are lacking. There are other behavioural factors, such as a history of smoking, which seem to play a role.

But what actually kicks off a cluster headache attack (or, what triggers a cluster period)?

Cluster isn’t as closely connected to “triggers”, such as food or hormonal changes, as migraine is. There are some factors which have been related to periods of cluster headache attacks, including smoking, sleep apnea, and the season of the year (autumn being the highest risk time of year).

Once the cycle has started, there may be other individual cluster headache causes. Alcohol is commonly reported, as well as strong chemical fumes. A hot day, or getting “overheated” during exercise seems to trigger attacks for some. However, when you’re not in a “cluster period”, these things will not trigger attacks at all.

Cluster is hard to research because it is so rare. However, we are learning more and more about the brain, and the last 30 years has brought us incredible advances in understanding. Many of these new revelations about cluster headache causes have brought new treatments to the forefront, such as deep brain stimulation for chronic cluster headache patients.

Further reading: Cluster headaches causes and treatments (Medical News Today)

Antibodies for Migraine: Finding a Target

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A huge emerging area of medical treatment is in the study and use of antibodies. Imagine if you were a sharpshooter, with a special gun that could attack certain cells or substances in the body. There would be little or no collateral damage – the bullets would only hit what you wanted to hit.

Now imagine that you could use that gun (an antibody medication) to shoot the messengers that were carrying around pain signals in your body – and in this way you could stop a headache in its tracks.

Antibodies for MigraineSounds great, doesn’t it? That’s what many many researchers around the world are thinking too. Though a relatively new field, it’s growing quickly, especially in conditions such as cancer and immune related diseases (such as Crohn’s disease and multiple sclerosis).

And, of course, this type of treatment has caught the imagination of migraine specialists. But the question becomes – what should the antibody gun shoot at?

The use of monoclonal antibodies directed against CGRP (calcitonin gene-related peptide neurotransmitter) is probably the hottest area of research in the area of antibodies for migraine. CGRP is the target, and this type of medication is showing a lot of promise as multiple companies race to get it the market. (Read more: The “Revolution” in Migraine Treatment (Dr. Peter Goadsby))

But there are other targets that are being researched. For example, Dr. Yu-Qing Cao of the Washington University Pain Center has carried out research (funded by the Migraine Research Foundation) on cytokines and chemokines as new targets for the antibody sharpshooters.

Cytokines and chemokines? What are they? Well, they’re types of protein in the body that coordinate immune responses. They’re handy to have around, but when they get out of control they can cause inflammation and degeneration on a neurological scale.

There are certain proteins that may rise in headache patients – could we shoot them down and stop the headache?

In a trial with mice (you have to start somewhere), the results of the proper antibodies were promising.

Drugs are already in the pipeline that could hit some of these migraine-specific targets, such as clazakizumab which is being developed for arthritis pain.

So this is what many researchers are doing – finding possible targets, looking for links with headache and migraine, and finding ways to shoot them down to keep them from causing problems, such as PAIN.

Check out the links below if you want to learn more. But if you want to help further migraine research, visit the Migraine Research Foundation and donate today (if you don’t need a tax receipt, or you’re outside of the USA, encourage our community by donating through this link. Either way the funds go directly to the MRF.)

My Favourite Posts of 2013 (and why I think they’re important for you to read)

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It’s time for the last post of 2013!  This is a special list – my own favourite posts that were not included in the previous list.  This time I’m going to list them and tell you why I think they’re important.  This time they’re in no particular order.

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