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8 Articles in this Series
AAPM's Advice for Evidence-Based Opioid Prescribing Guidelines
CBT for Chronic Pain and Insomnia Needs More Research
Farewell Opioid Therapy, Hello Mental and Behavioral Health
Ketamine’s Growing Use in Chronic Non-Cancer Pain Management
MR Neurography in CRPS Assessment
Navigating New Opioid Prescribing Requirements: Practical Legal Advice for PCPs & Pain Specialists
TACs: Identifying and Treating the Non-Migrainous Headache
Video: Dr. Aronoff on Shifts in Pain Care

TACs: Identifying and Treating the Non-Migrainous Headache


With presentation by Alexander Feoktistov, MD, PhD

Many pain and headache practitioners may be focused on the opportunities posed by the pending calcitonin gene-related peptide (CGRP) antibodies for the prevention of migraine, but novel treatment approaches for non-migrainous headache pain are being considered as well. Alexander Feoktistov, MD, PhD, co-director of the Diamond Headache Clinic, addressed the unique aspects of the TCA, or trigeminal autonomic cephalalgia population at the American Academy of Pain Medicine’s 2018 annual meeting. The panel also included presentations from James Watson, MD, and Narayan R. Kissoon, MD, of the Mayo Clinic.


Duration Can Differentiate Cluster Headaches from the Rest

TAC includes hemicrania continua, paroxysmal hemicrania, and SUNCT/SUNA, but Dr. Feoktistov primarily focused on the cluster headache TACs, which affect around 1% of the population and, unlike migraines, have a male to female ratio of about 2:4. Cluster headaches, he said, can occur at any age, but may peak in one’s 20s or 50s.

Cluster headaches can be intense and dramatic for the patient, and they require unique treatment, he explained. Compared to migraines, which may last several hours to a full day, are unilateral (but can switch sides), and have no autonomic symptoms, cluster headaches include:

  • a “locked side”
  • a short duration (15 minutes to 3 hours, typically)
  • autonomic symptoms (eg, congestion, eyelid oedema, facial sweating)
  • agitation and restlessness (patients may be rocking/pacing).

Cluster headache pain is usually very sharp, described as a stabbing feeling behind the eye or temple. Multiple attacks can occur in a single day, with as many as 8 attacks in 24 hours. Due to the rapid and intense onset, taking medication is often difficult, and with periods between attacks sometimes lasting a few months, patients often live wondering when the next one may arise. Fortunately, by digging into the patient’s headache duration and frequency, accurate diagnosis is likely, paving the way for effective treatment, said Dr. Feoktistov.



Treatment Approaches

Acute treatments using sumatriptain, zolmitriptan, and oxygen are most common while prophylactic therapy may involve sub occipital steroid injection, verapamil, lithium, melatonin, warfarin, or prednisone.

Paroxysmal hemicranias and hemicranias continua (headaches that may last several months (with fluctuation) differ from cluster headache in their response to indomethacin, a nonsteroidal anti-inflammatory drug (NSAID). In fact, noted Dr. Feoktistov, when other diagnostics are similar to cluster headache syndrome except for a patient’s reaction to indomethacin, that - along with duration/frequency of the pain - may help confirm the diagnosis. He advised using indomethacin in the smallest dose possible (150-225 mg/day) and noted that topiramate and gabapentin may also work for hemicranias continua, in particular, if the patient cannot tolerate NSAIDs. 

Indomethacin is worth a trial in patients with side-locked headaches, added Dr. Watson, MD, who serves as Mayo’s Vice Chair in the Department of Neurology for Analytics. Often pain clinics do not consider this medication but it has shown significant benefit in TAC headaches, he said.


More on Unilateral Head Pain

Finally, SUNCT/SUNA headaches (ie, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing / or with cranial autonomic features), last only 1 to 600 seconds in the form of blistering pain, with as many as 20 to 50 attacks in a 24-hour period. This type can be triggered without a refractory period and treatment is not standardized, although lidocaine IV infusion and other prolonged medications have had some effect, said Dr. Feoktistov.

Dr. Watson presented a case and imaging for the treatment of trigeminal neuralgia (SUNCT/SUNA), which he said involves sudden and severe attacks of unilateral facial pain, typically in one zone. There is, however, no clinically evident neurological deficit with this condition. He discussed the impact of sensory issues and how to differentiate trigeminal neuralgia from similar or overlapping conditions, such as trigeminal neuropathy and multiple sclerosis, and how to approach treatment, including microvascular decompression or gamma knife radiosurgery for different patient populations, including the young and the elderly.

Dr. Kissoon, a neurologist also affiliated with the Mayo Clinic, closed the panel with an overview of medication overuse headache (MOH), including diagnostic criteria. For example, MOH involves headache occurrence on at least 14 d/month and regular, as-needed abortive medication overuse over a period of 3 months. More specifically, a patient can use NSAIDs or acetaminophen up to 14 days per month and likely avoid MOH; for triptan, opioid, butalbital or combo analgesics, the timeframe for safely taking these medications and avoiding MOH is 9 days per month, he said.

Dr. Kissoon’s review also included clinical features and management of MOH, including patient communication about abrupt cessation/rapid taper effects, preventive medication options, and if needed, bridge therapy. Read more about MOH. Full slide decks are available on the AAPM Meeting Site. 

Of note, Dr. Feoktistov disclosed his role on the Lilly, Amgen and AMF advisory boards.


Feoktistov A, Watson J, Kissoon N. Not All Headaches are Migraines! A Practical Approach to Cranial Neuralgias, Unilateral, and Medication-Overuse Headaches. Presented at the American Academy of Pain Medicine Annual Meeting. April 26-29, 2018, Vancouver, British Columbia.

Next summary: Video: Dr. Aronoff on Shifts in Pain Care
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