Cluster Headache Triggers

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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.[1] Drinking alcohol triggers attacks in about half of the patients, red wine in 70%.[2] Triggers seldom have an influence on the start of a new cluster headache episode. Some heart medications for example can induce cluster headache episodes.[3]

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®)[4][5] and increased body heat (weather and climate dependant, sauna's, bathrooms etc).[6] Even the preventative Lithium is known to trigger attacks in some patients.[7]

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 nitrate (E249) and Sodium nitrate (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)

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 http://www.webcitation.org/5zGD4EdCF ) - 2009 replaced by: Institute for Clinical Systems Improvement (ICSI): Diagnosis and treatment of headache. Bloomington (MN), March 2009

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References and Literature

  1. Sances G, Tassorelli C, Pucci E, Ghiotto N, Sandrini G, Nappi G.: Reliability of the nitroglycerin provocative test in the diagnosis of neurovascular headaches. Cephalalgia. 2004 Feb; 24(2): 110-9. PMID 14728706, DOI.
  2. Schürks M, Kurth T, de Jesus J, Jonjic M, Rosskopf D, Diener HC.: Cluster headache: clinical presentation, lifestyle features, and medical treatment. Headache. 2006 Sep; 46(8): 1246-54. PMID 16942468, DOI.
  3. 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.
  4. 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.
  5. Evans RW.: Sildenafil can trigger cluster headaches. Headache. 2006 Jan; 46(1): 173-4. PMID 16412168 DOI.
  6. Blau JN, Engel HO.: A new cluster headache precipitant: increased body heat. Lancet. 1999 Sep 18; 354(9183): 1001-2. PMID 10501368 DOI.
  7. Brainin M, Eisenstädter A.: Lithium-triggered chronic cluster headache. Headache. 1985 Oct; 25(7): 394-5. PMID 3935601 DOI.

  • 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.

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