Beware of What is Lurking Below

When Determining Headache Causes

A fascinating piece of research clearly indicates that one needs to be aware of what is lurking below when determining causes of Cluster Headache, Migraine, Tension Headache, Menstrual Migraine and Hemicrania Continua.

Recent research has shown convincingly that migraine and other headache ‘conditions’ share a common disorder i.e., (‘central’) sensitisation of the lower brainstem/ trigemino cervical nucleus. One potential source of sensitisation of the brainstem is abnormal information from trigeminally innervated (intra and extracranial) structures. It is then interesting to find that cluster headache persists after blocking (i.e., sectioning) information carried by the trigeminal nerve i.e., sensitisation remains.¹

But What About Cervical Afferents

The authors’ conclusion was, wait for it… ‘The case illustrates that cluster headache may be generated primarily from within the brain.’ Yes, possibly… but what about cervical afferents… the beneficial effect of greater occipital nerve blocks² and occipital nerve stimulators?^3,4 This clearly demonstrates that (sensitisation in) headache or migraine can be initiated by other sources, e.g., afferent cervical information i.e., ‘what is lurking below’, and that the triptans act via a neural, central mechanism (i.e. DE-sensitising the brain stem).⁵ This patient’s cluster headache responded to a triptan before and after sectioning of the trigeminal nerve. The role of cervical afferents can be easily confirmed – i.e., reproduction and lessening of accustomed head pain and or symptoms⁶.

References

1. Matharu MS, Goadsby PJ. Persistence of attacks of cluster headache after trigeminal nerve root resection. Brain 2002;125(pt5):976-984
2. Peres MF, Stiles MA, Siow HC. Greater occipital nerve blockade for cluster headache. Cephalalgia 2002;22:520-522
3. Goadsby PJ. Neurostimulation in primary headache syndromes. Expert Rev Neurother 2007 Dec;7(12):1785-9
4. Wolter T, Kaube H, Mohadjer M. High cervical epidural neurostimulation for cluster headache: case report and review of the literature. Cephalalgia 2008;28:1091-1094
5. Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain 1996; 119:1419-28
6. Watson DH, Drummond PD Cervical Referral of Head Pain in Migraineurs: Effects on the Nociceptive Blink Reflex. Headache 2014;54:1035-1045