Review Compares Migraine and Cluster Headache Similarities for Identifying Treatment Options

A review, published by The Journal of Headache and Pain, evaluated past and current literature involving the phenotype, pathophysiology, triggers, imaging findings, and treatment options of migraine and cluster headache and emphasized how their shared pathophysiological pathways may be important for identifying future treatments.

The authors explained that migraine and cluster headache pain are often due to the activation of the trigeminovascular system. Furthermore, migraine and cluster headache patients share a significant number of common triggers from naturally occurring events (stress, sleep, alcohol intake, weather changes), as well as pharmacological triggers. These triggers are known as trigeminal system activators.

“Identification and avoidance of attack triggers plays an important role in management of patients with migraine and [cluster headache]. Attack triggers may also provide clues to their underlying pathophysiology,” stated the authors. “While naturally occurring attack triggers are useful in management of individual patients they may be of limited use in experimental provocation studies. Thus, in a study of self-reported triggers of migraine with aura only 17% of patients developed an attack following exposure to their natural attack trigger.”

When considering treatment, migraine and cluster headache therapy typically involves acute therapy to abort the single attack and preventative therapy to reduce attack frequency, duration, severity, and the use of acute headache medications, according to the authors.

Cluster headaches attacks commonly respond well to acute therapy with triptans. However, the oral route of administration is not often recommended due to the delayed effect when compared to subcutaneous administration, for example. Other acute approaches for cluster headache attacks include the inhalation of 100% oxygen through a face mask. The review also explained that most of the drugs used for cluster headache prophylaxis also showed efficacy in migraine prophylaxis—demonstrating the similarities of their basic pathophysiological mechanisms.

The authors also mentioned how recent data has demonstrated the efficacy of anti-calcitonin gene-related peptide (CGRP) monoclonal antibodies in both migraine and cluster headache. However, the review noted the need for future studies for additional data involving the similarities of the pathophysiology of migraine and cluster headache

“Migraine and cluster headache show remarkable similarities with common triggers, efficacy of triptans, anti-CGRP monoclonal antibodies, and neuromodulation,” concluded the authors. “These observations raise an important question on possible shared pathophysiological mechanisms. The central denominator in both diseases may be the trigeminovascular pathway, alteration in hypothalamic activity and functional changes in hypothalamic— brainstem connectivity.”