Headache Medicine, v.2, n.1, p.33-35, jan./feb./mar. 2011 33

Allodynia in cluster headache: a review

Alodinia na cefaleia em salvas: uma revisãoAlodinia na cefaleia em salvas: uma revisão

Alodinia na cefaleia em salvas: uma revisão

ABSTRACTABSTRACT

ABSTRACT

Allodynia is defined as the experience of pain due to non-

painful stimuli, and occurs in several clinical contexts,

including primary headaches. Cluster headache is a primary

cephalalgia which is more common in males, characterized

by excruciating pain, and autonomic trigeminal dysfunction.

The prevalence of allodynia in cluster headache patients is a

relevant matter with few studies devoted to. Thus, the need for

more information demanded a review of most important studies

to value the amount of data and its relevance. To bring light

to this yet blurry matter, it was made a review using the terms

"allodynia" and "cluster headache" through the CAPES

periodics, accessing the most relevant studies regarding to

this association.

Keywords:Keywords:

Keywords: Allodynia; Cluster headache

RESUMORESUMO

RESUMO

Alodinia é definida como a experiência de dor por estímulos

não dolorosos, e ocorre em vários contextos clínicos, incluin-

do aquele das cefaleias primárias. A cefaleia em salvas é uma

cefalalgia primária que é mais comum em homens, caracteri-

zada por dor excruciante e disfunção autonômica. A prevalência

da alodinia em pacientes com cefaleia em salvas é um assunto

relevante ao qual há poucos estudos devotados. Assim, a ne-

cessidade de mais informação demandou a revisão dos mais

relevantes estudos, para estabelecer o valor da quantidade de

dados e sua relevância. Para trazer luz a este ainda nebuloso

assunto, foi feita uma revisão usando os termos "alodinia" e

"cefaleia em salvas" através dos periódicos CAPES, abordando

os estudos mais relevantes relativos a esta associação.

Descritores: Descritores:

Descritores: Alodinia; cefaleia em salvas

REVIEW ARTICLEREVIEW ARTICLE

REVIEW ARTICLE

Elder Machado Leite

; Hugo André de Lima Martins

; Marcelo Moraes Valença

Mestrando em Neuropsiquiatria e Ciências do Comportamento da

Universidade Federal de Pernambuco – Recife, PE, Brazil

Doutor em Neuropsiquiatria e Ciências do Comportamento da

Universidade Federal de Pernambuco – Recife, PE, Brazil

Professor Associado da Universidade Federal de Pernambuco – Recife, PE, Brazil

Leite EM, Martins HA, Valença MM

Allodynia in cluster headache: a review. Headache Medicine. 2011;2(1):33-35

INTRODUCTION

Cluster headache (CH) is defined as the primary

cephalalgia which lasts 15 to 180 minutes, sited around

the orbit (periorbital, temporal and in frontal areas), usually

afflicting the same side of the head cluster after cluster,

obsessively, with autonomic trigeminal dysfunction (tearing,

conjunctival injection, rhinorhea, localized sweating, eyelid

edema, and ptosis). These symptoms and signs occur

commonly up to eight times a day. In episodic forms of

CH the patients may experience periods of weeks, months

or even years without symptoms. The clusters recur

periodically, usually on the same season, or yet at the

same time of day. These characteristics are gathered by

the classification proposed by the International Headache

Society.

(1)

Allodynia is the phenomenon which the subject feels

pain due to non-painful stimulus.

(2)

Thus, it is possible that

the descending pain modulating paths are involved, as

the hypothalamus, trigeminal paths and autonomic

structures. According to several authors, the prevalence

of allodynia in CH patients is still a theme for debate. A

particular study shows a relevant prevalence, up to 49%,

and others consider this association a rare entity.

(3)

METHODOLOGY

To bring light to this yet blurry matter, a review was

made using the terms "allodynia" and "cluster headache"

34 Headache Medicine, v.2, n.1, p.33-35, jan./feb./marc. 2011

LEITE EM, MARTINS HA, VALENÇA MM

through the CAPES periodics, accessing the most relevant

studies regarding to this association. The scrutiny used in

this review developed a methodological assessment as

follows:1– to observe the number of patients involved in

each of the studies; 2 – to analyze the method of allodynia

detection ; 3 – to describe the skin areas put to test; 4 – to

analyze the gender distribution of patients for each study;

5 – to describe the type of cluster headache (episodic or

chronic) in each study; 6 – to describe the mean duration

of disease; 7 – to analyze the prevalence results.

REVIEW

This primary headache also might be divided in two

major subtypes: episodic CH and chronic CH. The criteria

for this separation are well established, and when the

attacks occur for more than one year without remission,

or with remissions that last less than 14 days, then it fulfills

the features for the chronic form. Otherwise, when the

remissions last 14 days or more, and the attacks last seven

days to one year, it is defined as the episodic form.

(1)

In addition to these major subtypes, there is another

subdivision applied to the chronic cluster headache, which

defines the ones having a temporal pattern typical of

chronic forms since the onset as chronic CH unremitting

form. And the others that evolve from an initial episodic

pattern into the chronic features are named secondary

chronic forms. There is also the CH which has a chronic

pattern by the onset, and then evolves into an episodic

one, namely secondary episodic pattern, even though it

is the rarest form, it seems relevant to mention.

(4)

Concerning to the clinical characteristics of this primary

headache, it is imperative to mention that unlikely most

headaches, CH are far more common in males. There

are studies form 1979 and 1982 describing a ratio of 5

to 1, and even 9 to 1 men to female.

(5,6)

In more recent

works the authors describe a decline in this male to female

preponderance, with ratios of 2.4:1 and 3.2:1 male to

female in chronic CH in episodic forms and chronic CH

in unremitting forms, respectively.

(7)

Regarding to treatment, it is also necessary to

fractionate into abortive and prophylactic treatment. In

acute situations the abortive methods encompass the

oxygen inhalation at 100%, the use of subcutaneous

sumatriptan, dihydroergotamine in injectable and

intranasal forms, intranasal lydocaine, and as a resource

for oral treatment it has been mentioned the zolmitriptan.

The prophylaxis commonly involves verapamil as the main

alternative, and other drugs as lithium carbonate,

methysergide, valproic acid, topiramate, melatonin,

capsaicin, indometacin, prednisone, gabapentin and

some antipsychothic drugs, namely olanzapin and

clorpromazin. Other studies, small and open-labled ones,

mention methylphenidatem tizanidine, histamine,

somatostatin and pizotifen.

(4)

It is worth to point out, related to therapeutics, a case

of a 32 years old pregnant woman, who suffered from

CH, and whose response to oxygen treatment was none,

who had a relief with intranasal lydocaine. As lydocaine

has minimal risk for the pregnant woman and fetus, due

to its low toxicity, it may be useful as a primary step in

acute treatment for CH pregnant patients.

(8)

And there is

also a case report describing remission of refractory chronic

CH after warfarin administration.

(9)

RELATIONS AMONG ALLODYNIA AND

CLUSTER HEADACHE

Regarding to the number of patients involved in each

of the main studies, accessing the association between

allodynia and CH, it is remarkable that there is no study

with a great number of patients. It is understandable when

one considers the low prevalence of cluster headache in

general population, affecting 0.01% to 0.9% of general

population, and representing 8% to 10% of headache

patients.

(10,11)

The number of patients with CH tested for

allodynia in all studies analyzed vary from as few as two

(12)

to as much as 41.

(3)

Considering the method of allodynia detection, one

study used a pin prick testing in two patients.

(12)

Another

study by Ashkenazi et al. used a test for brush allodynia

(BA) in ten male patients, which was performed using a

4 x 4 - inch gauze pad, applied repetitively at a rate of

two per second, to six skin areas bilaterally in trigeminal

and cervical distributions [frontal (V1), maxillary (V2),

mandibular (V3), posterior neck (C2,C3), shoulder (C5),

and inner forearm(C8)].

(13)

Ladda et al. used a

quantitative sensory test performed in 16 CH patients

and ten healthy ones. This method aimed to determine

the subjects perception and pain thresholds for thermal

(use of thermode) and mechanical (vibrations, pressure

pain thresholds, pin prick, von Frey hairs) stimuli.

(14)

Marmura et al. also used the same test for BA described

above.

(3)

The skin areas put to test by Ladda et al. were the

right and left cheeks and the back of right and left

hands.

(14)

Marmura et al., nevertheless, tested the forehead

(V1), posterior neck (C2/C3) and inner forearm (C8) on

Headache Medicine, v.2, n.1, p.33-35, jan./feb./mar. 2011 35

ALLODYNIA IN CLUSTER HEADACHE: A REVIEW

both sides.

(3)

Ashkenazi et al. approached six skin areas

bilaterally in trigeminal and cervical distributions [frontal

(V1), maxillary (V2), mandibular (V3), porterior neck

(C2,C3), shoulder (C5), and inner forearm (C8)].

(13)

one study, a series of cases, Riederer et al. did not mention

the skin areas put to test.

(12)

When an analysis approaches the gender distribution

through the studies, the males are the majority. Marmura

et al. encompass 22 males and 19 females in the study.

(3)

Ashkenazi et al. interestingly includes 10 males and no

females.

(13)

In the study by Riederer et al. males and

females comprise equal parts, but this particular study

presents only one man and one woman, making any

assumptions regarding gender unreliable.

(12)

Taking into account the types of CH, whether episodic

or chronic, the literature includes a short series of cases

with two episodic cluster headache (ECH) patients.

(14)

Another study made by Ashkenazi et al. included seven

ECH and three chronic cluster headache (CCH) patients.

(13)

And Marmura et al. describes 22 CCH and 19 ECH

patients.(3) The study made by Ladda et al. comprises 8

CCH and 8 ECH patients.

(14)

Moving towards the mean duration of disease,

Marmura et al. described a 14.1 years duration (12.3

for CCH group and 15.7 for ECH group), Ashkenazi et

al. reports a duration from 18 months to 38 years.

(3,13)

Riederer et al. in his series contemplates one patient with

a 13 year history of ECH and another patient with a 20

years history also of ECH.

(12)

As a final regard, the prevalence of allodynia in CH

patients according to Marmura et al. was 49%; and 40%

(28.6% for ECH patients, and 66.7% for CCH patients)

according to Ashkenazi et al.

(3,13)

Although reporting

allodynia during the attacks, both patients included by

Riederer et al. tested negative for allodynia.

(12)

Ladda et

al. found no allodynia in three patients examined during

the attacks, but a significant difference in pain thresholds.

(14)

CONCLUSION

Cluster Headache patients do not represent an

insignificant part of all headache patients, and thus this

clinical entity cannot go on being considered as a worthless

rare headache. The few authors devoted to this relevant

matter are mentioned repeatedly, making it evident the

need for more research and interest. The prevalence of

allodynia in CH is a theme which was neglected until recent

times, and the small number of studies demands more

attention, and finally more prevalence studies.

REFERENCES

1. Headache Classification Committee of the International

Headache Society. Classification and diagnostic criteria for

headache disorders, cranial neuralgias an facial pain.

Cephalalgia 1988; 8 (Suppl. 7):1-96.

2. Campbell WW. O sistema sensorial. In: Campbell WW. DeJong

O Exame Neurológico Rio de Janeiro: Guanabara Koogan;

2007. p. 357-62.

3. Marmura MJ, Abbas M, Ashkenazi A. Dynamic mechanical (brush)

allodynia in cluster headache: a prevalence study in a tertiary

headache clinic. J Headache Pain. 2009;10(4):255-8.

4. Dodick DW, Rozen TD, Goadsby PJ, Silberstein SD. Cluster

Headache. Cephalalgia. 20(9):787-803.

5. Kudrow L. Cluster headache: diagnostic management. Headache

1979; 19(3):142-50.

6. Kunkel RS. Classification of cluster headache. Clinical features

of episodic cluster headache. In: Cluster Headache. A

comprehensive Course. New Orleans: American Association

for the Study of Headache; 1982; 8p.

7. Torelli P, ColognoD, Cademartiri C, Manzoni GC. Primary and

secundary chronic cluster headache: two separate entities?

Cephalalgia. 2000; 20(9):826-9.

8. Giraud P, Chauvet S. Cluster headache during pregnancy: case

report and literature review. Headache 2008; 49(1):136-9.

9. Souza JA, Filho PFM, Jevoux CC, Martins GF, Pitombo AB.

Remission of refractory chronic cluster headache after warfarin

administrations: case report. Arq Neuropsiquiatr. 2004;

62(4):1090-1

10. Volcy M, Tepper SJ. Cluster-like headache secondary to

idiopathic intracranial hypertension. Cephalalgia. 2006;

26(7):883-6.

11. Galvão ACR, Fortini I. Outras cefaléias primárias e cefaléias

secundárias. In: Teixeira MJ. DOR Manual para o Clínico São

Paulo: Atheneu; 2006. p. 343-356.

12. Riederer F, Slelkler HM, Sándor PS, Wöber C. Cutaneous

allodynia during cluster headache attacks. Cephalalgia. 2009;

29(7):796-8.

13. Ashkenazi A, Young WB. Dynamic mechanical Allodýnia in cluster

headache. Headache. 2004;44(10):1010-2.

14. Ladda J, Straube A, Förderreuther S, Krause P, Eggert T.

Quantitative sensory testing in cluster headache: increased

sensory thresholds. Cephalalgia. 2006;26(9):1043-50.

Comment in Cephalalgia. 2006;26(9):1041-2.

Correspondence

DrDr

. Elder Machado L. Elder Machado L

. Elder Machado L

eiteeite

eite

Rua Alcina da Mota Valença, nº 685 – Heliópolis

55296190 – Garanhuns, PE, Brasil