Cluster Headache Triggers

During a cluster headache episode and in chronic cluster headache patients, cluster headache attacks can often but not always be triggered by histamine or by nitroglycerin. Drinking alcohol triggers attacks in about half of the patients, red wine in 70%. Triggers seldom have an influence on the start of a new cluster headache episode. Some heart medications for example can induce cluster headache episodes.

Triggering factors

The exact causes of CH are not fully researched. One may suspect, that because of genetic make-up, a CH affected brain responds more sensitive from healthy people. Bodily changes, like hormonal swings in daily or annual rhythm, or changing outer influences may trigger a hit. Those inner and outer influences, that will provoke a CH, are called triggering factors. They are however not the actual cause.

Which triggers will provoke an attack, is hugely individual and may differ from one person to another. For one, changes in stress level can play a role, for another a change in sleeping patterns, such as the weekend. In many patients, nutrition and stimulants are a factor. It is in any way usefull to find them with a doctor, so they can be avoided.

It helps to keep a headache-diary. as available through headache-specialists such as neurologists and anaestesists. Then jot down the date, hour, duration, painlevel and the exact sort of aching, medication used and suspected triggers.

It is senseless avoiding known foodtriggers, as not all CH-sufferers experience them as such.

Important is to exclude only those specific foods, whom come forth as personal triggers, through the use of the headache-diary. While trying to detect them, one should remember there are oftentimes hours, sometimes even a day, between ingesting and the following hit. Even when patients find out, which ones provoke them, they sometimes happen to tolerate them when there are no other disturbing factors. Only when consequent troubling factors rock the boat, foodtriggers will release an attack. Also, preventatives like Verapamil, will decrease or even solve trigger sensitivity.

Scientifically researched and documented triggering factors are Glycerintrinitrate (nitroglycerin in the form of cardio medication) and histamine. Reported are also Sildenafil (Viagra®) and increased body heat (weather and climate dependant, sauna's, bathrooms etc). A single case report from 1985 describes one person in whom chronic cluster headache followed treatment with lithium, a drug normally used for prevention.

Known triggers

Cluster headache patients report the following suspected triggers:

• Alcohol, especially red wine and wheat beer (contains histamin)
• Monosodium glutamate aka MSG which is a flavour enhancer found in almost any industrially processed food (glutamic acid). In natural form to be found in cheese and tomatoes. Chinese food and other Asian dishes are commonly seasoned with glutamic acid, as are canned soups.
• Potassium nitrite (E249) and sodium nitrite (E250), mainly found in sausages and other processed meat.
• Artificial sweetener e.g. Aspartame
• Fish and seafruit.
• Chocolat.
• Cheese.
• Tomatoes.
• Nuts.
• Citrusses and/or lemon juice.
• Strawberries.
• Feeling hungry, irregular meals.
• Flickering lights, TV, computer, cinema screen, beamer.
• Altitude, flying.
• Napping, changing sleeping patterns.
• Odours such as: petrol, alcohol, terpentine, glue, dissolvants, smell of fish, detergents (for cleaning), perfumes, scentcandles.
• Having a cold/ medication for colds.
• Noise.
• Heat, airdraft, airconditioning.

Nutrition

As a healthy, well-balanced diet consisting of fresh quality products works positively on the entire organism, it is generally recommended. Some patients reported good results from low purine or from low histamine diets.

Statistical survey

Results from a survey of German CH support groups in a 2003 poll may not be fully representative. 38 out of 76 participants changed their diets.

Out of these 38:

• Avoiding triggers 78.9% (good or moderate results: 72% of the 78.9%)
• Reduction of fats 31.6% (good or moderate results 32% of the 31.6%)
• Low purine / gout diet (Uric acid reduction) 26.3% (good or mild results 24%)
• Reduction of cholesterols 34.2% (good or moderate results 28%)
• Becoming vegatarian 10.5% (good or moderate results 12%)
• Others: no more alcohol (mentioned 3 times), lots of water, glutenfree diet, Renneberg (gout) diet, reducing acidosis, no drugs, no sweets/candy.

The 76 people mentioned the following triggers:

• Alcohol 50%
• Flickering lights 33%
• Blinding lights 24%
• Food additives 22%
• Smells 20%
• Certain cheese 18%
• Noise (including music) 16%
• Tomatoes and/or products made from tomatoes 13%
• Citrusses 5%

Others (number of times mentioned):

• Glutamic acid 12
• Chocolate 4
• Histamine 3
• Solvents/lacquer 3
• Sports, airdrafts, airconditioning, bananas (each mentioned twice)
• Gluten, tyramine, glutamic acid, cinnamon, aniseed, Maggi-spices, spinach, dairy products, legume (such as peas, alfalfa, peanuts), marmalade, liquorice, peppermint, nuts, disinfectants, etherical oils, gas stations, nicotin, fatigue, stress, sauna's, hot steam, humidity, carrying heavy load/moving, same bodyposition in theatre (each mentioned once).

Nearly three times the amount of episodics, as opposed to chronics, stated to be unaware or not responding to triggers (chronics 12.9% - episodics 36.2%).

Out of the 76 patients:

• 50% are episodic
• 14.5% chronic from the start
• 26.3% episodic turned chronic
• 11.8% chronic turned episodic

US Guideline: Treatment of primary headache: cluster headache (2004)

This list reflects a US guideline from 2004. The US guideline database that held it (National Guideline Clearinghouse) was shut down in 2018. It is not a current recommendation. The European guideline of 2023 contains no such list of things to avoid; it notes that during the cluster period, attacks can be triggered by alcohol, nitroglycerin or histamine.

Nondrug Treatment Strategies

• Patients should avoid the following:

1. Afternoon naps or other significant changes in their sleeping habits

2. Alcohol, especially during the cluster period

3. Prolonged exposure to chemical agents such as cleaning solvents, gasoline, and oil-based paint

4. Excessive bursts of anger or extreme emotion

5. Prolonged physical exertion

6. Extreme changes in altitude

Source: Biondi D, Mendes P.: Treatment of primary headache: cluster headache. In: Standards of care for headache diagnosis and treatment. Chicago (IL): US National Headache Foundation; 2004. p. 59-72. US National Guideline Clearinghouse (NGC). 2004 (Archived by WebCite® at https://www.webcitation.org/5zGD4EdCF ) - 2009 replaced by: Institute for Clinical Systems Improvement (ICSI): Diagnosis and treatment of headache. Bloomington (MN), March 2009

References and Literature

---

• Ärzte Informationen Cluster-Kopfschmerz der Ambulanz für Schmerztherapie der Klinik für Anaesthesiologie der Heinrich-Heine-Universität Düsseldorf (PDF-Datei, siehe Seiten 25-27)
• DMKG: Patientenratgeber Ernährung und Migräne (PDF-Datei)
• IHS-ICHDII 8.0
• Kommentar zu: Peatfield R.C., Fletcher G., Rhodes, K., Gardiner I.M., de Belleroche J. Pharmacological analysis of red-wine-induced migrainous headaches. J Headache Pain 2003, 4, 18-23 in der DMKG Kopfschmerz-News 04/2003, Seite 15 (PDF-Datei)
• Reinhard Jarisch: Histamin-Intoleranz, Histamin und Seekrankheit. Thieme Verlag 2004. ISBN 3-13-105382-8
• Laura Maintz, Thomas Bieber, Natalija Novak: Die verschiedenen Gesichter der Histaminintoleranz. Dtsch Arztebl. 2006; 103 (51–52):A 3477–83. PDF-Datei
• E. Renneberg: Clusterkopfschmerz, Schmerzfrei durch Ernährungsänderung, Selbstverlag 2004, http://www.renneberg-online.de/
• US Richtlinie: Treatment of primary headache: cluster headache. Standards of care for headache diagnosis and treatment
• Schurks M. et al.: Cluster headache: clinical presentation, lifestyle features, and medical treatment. Headache. (2006) 46(8):1246-54 PMID 16942468.
• Sancez et al.: Reliability of the nitroglycerin provocative test in the diagnosis of neurovascular headaches. Cephalalgia. 2004 Feb;24(2):110-9. PMID 14728706
• Costa et al.: Nitric oxide pathway and response to nitroglycerin in cluster headache patients: plasma nitrite and citrulline levels. Cephalalgia. 2003 Jul;23(6):407-13. PMID 12807519
• Fanciullacci et al.: Responsiveness of the trigeminovascular system to nitroglycerine in cluster headache patients. Brain (1997), 120, 283–288 (PDF-Datei) PMID 9117375 - Kommentar dazu in der DMKG Kopfschmerz-News Juni 1997
• Evans RW.: Sildenafil can trigger cluster headaches. Headache. 2006 Jan; 46(1): 173-4. PMID 16412168 DOI.
• de L Figuerola M, Bruera O, Lestón J, Ferreiro J.: Cluster headache attack due to sildenafil intake. Cephalalgia. 2006 May;26(5): 617-9. PMID 16674772 DOI.
• Ekbom K, Sjöstrand C, Svensson DA, Waldenlind E.: Periods of cluster headache induced by nitrate therapy and spontaneous remission of angina pectoris during active clusters. Cephalalgia. 2004 Feb;24(2): 92-8. PMID 14728704 DOI.
• Robbins L.: Case report: cluster headache precipitated by isosorbide mononitrate. AJPM. 2004; 14(1): 10-12. PDF-Datei

• de Belleroche et al.: Erythrocyte choline concentrations and cluster headache. Br Med J (Clin Res Ed). 1984 Jan 28;288(6413):268-70. PMID 6419890
• Thomsen et al.: Nitric oxide in primary headaches. Curr Opin Neurol. 2001 Jun;14(3):315-21. PMID 11371754
• Blau JN, Engel HO.: A new cluster headache precipitant: increased body heat. Lancet. 1999 Sep 18; 354(9183): 1001-2. PMID 10501368 DOI.
• Brainin M, Eisenstädter A.: Lithium-triggered chronic cluster headache. Headache. 1985 Oct; 25(7): 394-5. PMID 3935601 DOI.
• Sjaastad: Histamine metabolism in cluster headache and migraine. J Neurol. 1977 Sep 12;216(2) PMID 72800, PMID 72805
• Irlbacher K, Meyer BU.: Nasally triggered headache. Neurology. 2002 Jan 22; 58(2): 294. PMID 11805260. Online.
  • Farber RE.: Nasally triggered headache. Neurology. 2002 Jul 9; 59(1):151; PMID 12105334. Online.
• Lambert GA, Zagami AS.: The Mode of Action of Migraine Triggers: A Hypothesis. Headache. February 2009; 49(2): 253-75. PMID 18793210 DOI.

• Mukamal KJ, Wellenius GA, Suh HH, Mittleman MA.: Weather and air pollution as triggers of severe headaches. Neurology. 2009 Mar 10; 72(10): 922-7. PMID 19273827 DOI.
  • https://www.aerzteblatt.de/nachrichten/35750

• Ferrari A, Spaccapelo L, Pinetti D, Tacchi R, Bertolini A.: Effective prophylactic treatments of migraine lower plasma glutamate levels. Cephalalgia. April 2009; 29(4): 423-9. PMID 19170689 DOI.

• Benemei S, Appendino G, Geppetti P (September 2009). "Pleasant natural scent with unpleasant effects: cluster headache-like attacks triggered by Umbellularia californica". Cephalalgia. doi:10.1111/j.1468-2982.2009.01988.x. PMID 19732077.  PDF Comment A. Sewell: A tree that causes cluster headache? April 2nd, 2010

• Gelbe Liste: Präparate, die den Wirkstoff Isosorbidmononitrat enthalten

External Links

• H. Rupp: "Versteckte Trigger"
• http://www.alles-zur-allergologie.de/Allergologie/Artikel/3526/Allergen,Allergie/Histamin.html
• Inhaltsstoffe von Lebensmitteln: U.S. Department of Agriculture - Food and Nutrition
• OUCH-US: Non-Prescription Cluster Help
• OUCH-US: CH and Apnea
• The Cluster Headache Book: Triggers
• CH.com MB Topic Food Triggers???
• CH.com MB Topic Weird Triggers....
• https://www.clusterheadaches.com/cgi-bin/yabb2/YaBB.pl?num=1215630530

Diese Seiten sind von Nichtmedizinern geschrieben und ersetzen keinen Arztbesuch. Angaben können fehlerhaft oder veraltet sein – prüfen Sie Wichtiges in den genannten Quellen nach. Bitte beachten Sie die Hinweise zu Gesundheitsthemen und zum Datenschutz sowie unsere Arbeitsweise.