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Updates in cluster headache PCPs need to know
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PHILADELPHIA — There have been a range of changes in the management of cluster headaches over the last year, including the approval of several new pharmaceutical options options and abandoning plans for a treatment alternative, according to a presentation at the American Headache Society Annual Scientific Meeting.
Role of galcanezumab, fremanezumab
Two medications approved by the FDA in 2018 for the prevention of migraine— Emgality (galcanezumab, Eli Lilly and Company) and Ajovy (fremanezumab, Teva) — were assessed in patients with cluster headache, according to Stewart Tepper, MD, professor of neurology at the Geisel School of Medicine at Dartmouth College.
The FDA expanded the indications for galcanezumab to include reducing the frequency of episodic cluster headache, however data showed it was not effective in preventing chronic cluster headache.
In other research, fremanezumab was not effective in reducing the weekly average number of episodic cluster headaches or chronic cluster headaches.
“This is a very encouraging development as we better understand cluster headache and treatments for the condition,” Tepper said of galcanezumab.
Precursors, genetics studied
Pre-elliptical and post-elliptical features of cluster headache have remained largely unknown, but a recent study shed new light on the topic, Tepper said.
Researchers analyzed 57 patients and 500 attacks, and concluded that in about half the cases of cluster headaches, patients reported local pain 10 minutes before symptom onset. Also in about half of cases, patients reported concentration problems, restlessness and mood changes about 20 minutes before the headaches started.
“These symptoms sound limbic to me,” Tepper said, adding that 1 hour after the pain began, a “median number” of patients in the study still had fatigue, decreased energy and difficulty concentrating.
Two recent studies in Sweden used a cohort of 542 patients with the condition and 581 controls to identify genetic risk factors for cluster headache. The researchers concluded that although presence of rs1835740 is a potential risk factor, rs12668955 and rs1006417 are not.
“These researchers looked at coding for metadherin,” Tepper explained. “The associations they found tended to be more powerful for when cluster and migraine overlap.”
Plans scrapped for sphenopalatine ganglion -microstimulator system
Previously published research in Headache indicated that patients with cluster headaches have few therapeutic options and as many as one in five patients develop drug-resistant symptoms attacks.
A potential treatment option for these patients that was being explored was the noninvasive sphenopalatine ganglion-microstimulator, and ‘encouraging’ data were presented at the American Headache Society’s 2018 Annual Scientific Meeting were encouraging, Tepper said. That product has likely been abandoned, he said.
“The FDA also was not satisfied with the toxicology studies on the device’s implant material and requested another such study. However, the manufacturer went into receivership before it could conduct those studies,” Tepper explained.
Prevalence data released
Results of an online survey released at the American Headache Society Annual Scientific Meeting provided some rare insight into the prevalence of cluster headache.
Mark Burish, MD, PhD, of the University of Texas Health Science Center in Houston, and colleagues facilitated and analyzed results from an online survey consisting of 2,913 participants from 61 countries.
They found that 1,604 of the survey responders had definite cluster headache, and of those, 69% were male and 21% experienced their first headache cluster before they reached 18 years of age; they added that some of their results conflict with prior research in this area.
In addition, 97% of the responders said they “had never experienced anything more painful than a cluster attack.”
By way of comparison, the next highest painful conditions patients reported were childbirth, pancreatitis and kidney stone, and those conditions had pain scores that averaged about two points less than cluster headache.
“Cluster headache is one of the most painful human experiences according to this large international survey. Pediatric cluster headache may be more common than previously thought,” Burish and colleagues wrote.
Previous polled data published in Cephalalgia from 2008, one of few previous studies to examine cluster headache prevalence, suggested the lifetime prevalence of cluster headache numbers at approximately 124 per 100,000 persons, a 1-year prevalence of 53 per 100,000 persons, and that males were more likely to develop the condition. – by Janel Miller
References:
Burish M, et al. Cluster headache is one of the most painful human conditions: Epidemiology of cluster headache and probable cluster headache from a large international sample.
Tepper, S. Cluster headache — What’s new in science and practical clinical management. Presented at: American Headache Society Annual Scientific Meeting; July 11-14, 2019; Philadelphia.
Also:
Fischera M, et al. Cephalalgia. 2008;doi:10.1111/j.1468-2982.2008.01592.
Ran C, et al. J Headache Pain. 2018;doi:10.1186/s10194-018-0937-0.
Ran C, et al. J Headache Pain. 2018;doi:10.1186/s10194-017-0798-y.
Snoer A, et al. Cephalalgia. doi.org/10.1177/0333102417726498.
Tepper SJ, Caparso A. Headache. 2017;doi: 10.1111/head.1303.
Disclosures: Tepper reports receiving grants related to cluster headache research and serving as consultant and receiving stock options from several drug manufacturers, companies that make products that help patients with headache and medical societies. Healio Primary Care could not determine Burish and his colleagues’ relevant financial disclosures prior to publication. Please see the studies for those authors’ relevant financial disclosures.