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Latest Treatments for Cluster and Tension Headaches

New medical interventions for tension-type and cluster headaches are discussed.

Key points

  • Primary headaches include migraine, trigeminal autonomic cephalalgia (e.g., cluster headaches), and tension-type headaches.
  • Painkillers, antidepressants, behavioral therapies, and mind-body interventions are helpful in preventing/treating tension-type headaches.
  • Cluster headaches may be treated with triptans, pure oxygen treatment, and non-invasive vagus nerve stimulation.

In a paper published in the May issue of JAMA, M. S. Robbins, of Weill Cornell Medical College, reviews the diagnosis, prevention, and treatment of primary headaches.

In a previous post, I discussed migraine headaches, specifically the latest medical interventions for preventing and treating migraines.

In this post, I refer back to Robbins’ paper as I discuss tension-type headaches and trigeminal autonomic cephalalgias (mainly cluster headaches). See table below.

Let us begin with examining the prevention and treatment of tension-type headaches.

Arash Emamzadeh (adapted from Robbins, 2021)
Source: Arash Emamzadeh (adapted from Robbins, 2021)

Tension-type headaches

Tension-type headaches cause mild to moderate pain—tightness, dull pressure, or squeezing sensations (as if from a tight hat). A tension headache attack can last from 30 minutes to seven days. The pain is usually worse in the frontal and temporal (i.e., temples) areas, though it might be intense in other areas too (e.g., upper neck). Unlike migraines, tension headaches are not significantly exacerbated as a result of activity; nor are they typically associated with nausea, vomiting, or visual disturbances.

Episodic tension-type headaches are the most common primary headaches (one-year prevalence of approximately 40%). Chronic tension type-headaches—attacks on at least 15 days a month for three months—are less prevalent (2-3%) and often associated with medication overuse and mental health symptoms (e.g., anxiety and depression).

Many triggers for tension headaches have been reported: Psychological stress, fatigue, hunger, loud noises, lack of sleep, eyestrain, neck pain (e.g., due to injury, sleeping position, sitting posture), jaw pain (e.g., temporomandibular disorders related to arthritis, teeth grinding, etc.), alcohol and drug use, and mental health symptoms such as anxiety and depression.

The causes of tension-type headaches possibly involve both environmental and genetic factors (especially in the case of chronic headaches). In terms of the pathophysiology of episodic tension headaches, prevalent theories point to the role of myofascial activity/excitability and sensitization of pain receptors. Pathophysiology of chronic headaches may entail more general changes in the central nervous system pain circuitry and secondary sensitization.

Treatments for tension headache comprise simple analgesics (e.g., acetaminophen, brand name Tylenol); non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin (Bayer), ibuprofen (Advil, Motrin), ketorolac (Toradol), diclofenac (Voltaren), naproxen (Aleve), and combination medications containing caffeine. It is important not to take more medications (or more frequently) than recommended, as doing so might cause rebound headaches.

Preventive interventions, recommended when attacks are frequent or disabling, consist of tricyclic antidepressants amitriptyline (Elavil) and nortriptyline (Pamelor); the tetracyclic antidepressant mirtazapine (Remeron); and the serotonin-norepinephrine reuptake inhibitor venlafaxine (Effexor).

Other interventions, such as cognitive behavioral therapy, biofeedback, acupuncture, and trigger point injections, are recommended as well.

As with other health conditions, it is essential to consider making healthy lifestyle changes: better posture, proper sleep position, maintaining a regular wake-up and bedtime, physical exercise, staying hydrated, eating healthy, doing neck and shoulder stretches, practicing stress management techniques (e.g., mindfulness meditation, relaxation, deep breathing, yoga, massage), and modifying environmental factors (e.g., noise, heat, ergonomics). Last, it is helpful to treat health conditions like bruxism (teeth grinding) that aggravate tension headaches.

Cluster headaches

Cluster headaches are a very painful and rare type of primary headache (prevalence < 1%; more common in men). Attacks occur suddenly and last from 15-30 minutes to three hours. Cluster headaches are named so because they come in clusters, meaning there are weeks (sometimes even months) of frequent headaches, followed by long headache-free remission periods (months or years). During a cycle, attack frequency varies from every other day to as often as eight times per day.

Cluster headaches are characterized by severe pain (often intense throbbing, sharp, or searing sensations) on one side of the head, starting with above/behind one eye. This is accompanied by feelings of restlessness and agitation (e.g., rocking back and forth, pacing the room) and autonomic symptoms (e.g., drooping eyelids, constricted pupils, runny nose, forehead sweating, excessive tearing, eye redness, and swelling) on the same side as the headache. Occasional migraine symptoms, including light sensitivity, might also be present.

In 10% of the cases, episodic cluster headaches become chronic, lasting a year or more with no or short (e.g., 1-2 months) pain-free periods.

Cluster headaches often happen at night, and around the same time. Indeed, the sudden and intense pain has awakened many patients from sleep. Furthermore, the attacks tend to occur at the same time of the year (e.g., typically during seasonal changes, like the beginning of spring).

Some cluster headache triggers are bright lights, high altitude, increased body heat (e.g., hot weather), strong scents, foods containing nitrates, smoking, and use of drugs that dilate blood vessels (e.g., nitroglycerin, alcohol). Keeping a headache diary may help patients identify triggers that cause or worsen headaches, so they can avoid them during cluster periods.

Miroslavik/Pixabay
Source: Miroslavik/Pixabay

The cause of cluster headaches is still debated. The pathophysiology of cluster headaches is complex and seems to involve the hypothalamus (the biological clock). One view suggests cluster headache’s pathophysiology entails the hypothalamic activation of the trigeminal-autonomic reflex (the cause of the autonomic symptoms) and the trigeminovascular system on the same side of the head.

Treatment for cluster headaches consists of non-oral triptans, like intranasal zolmitriptan (Zomig) or intranasal/subcutaneous sumatriptan (Imitrex), which work by narrowing the blood vessels in the head; inhaling pure oxygen (flow rate of up to 15 liters per minute); and non-invasive vagus nerve stimulation (for episodic headaches).

Prevention comprises the use of calcium channel blockers like verapamil (Calan); lithium carbonate (Lithobid); monthly injections of monoclonal antibodies such as galcanezumab (Emgality); and adjunctive vagus nerve stimulation. Short-term preventive treatments include steroids, like prednisone (Deltasone), and occipital nerve blocks.

For chronic cluster headaches, sphenopalatine ganglion stimulation should be considered.

Other substances, namely melatonin and capsaicin, may help too, though more research in this area is needed. Finally, as with other health conditions, it is important to consider making healthy lifestyle changes (e.g., stress management, avoiding alcohol use, and sleep hygiene).

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