IV Histamine Desensitization for Cluster Headache - Brief Article

0 Comments | Family Practice News, May 1, 2000 | by Barbara Baker

RANCHO MIRAGE, CALIF. -- Patients with chronic cluster headaches recalcitrant to standard prophylactic agents have an alternative before resorting to surgery--intravenous histamine desensitization.

The approach, which involves a series of infusions with increasing amounts of histamine phosphate, resulted in significant improvements in intractable cluster headache in 48 of 59 patients, Dr. Seymour Diamond reported during a poster session at a meeting on treating the difficult headache patient.

Patients who responded to the desensitization therapy had had chronic cluster headaches for an average of almost 9 years prior to desensitization. Following desensitization, they had a renewed response to standard prophylactic agents that lasted for an average of 17 months, said Dr. Diamond, director of the Diamond Headache Clinic in Chicago, which sponsored the meeting.

Just why the treatment helps is not known, but investigators have observed mast cell degranulation with histamine release during duster headache attacks. Histamine desensitization may inhibit this degranulation, he speculated.

In a separate presentation at the meeting, Dr. Donald J. Dalessio commented that histamine desensitization can be an excellent option for chronic cluster headaches unresponsive to standard prophylactic agents. "It's a benign procedure that can produce striking results," he said.

Because the protocol is complicated and usually requires about 10 days of hospitalization, he refers his patients with intractable cluster headaches to the Diamond Headache Clinic for desensitization. If physicians are interested in learning the technique themselves, he recommended they contact the clinic and arrange training.

Before using histamine desensitization, a variety of pharmacologic prophylactic medications should be tried, stressed Dr. Dalessio, who is a senior consultant in neurology at Scripps Clinic and Research Foundation in La Jolla, Calif.

Ergotamine tartrate can be a good option for cluster attacks that occur only at night. For patients with attacks at all times of the day, choices include methysergide, verapamil, and divalproex. Lithium carbonate is also an option, although it carries a risk of several drug-drug interactions that restrict its use to select patients, he said.

It's worthwhile attempting drug combinations in patients who don't respond to single agents, Dr. Dalesslo added. A 7- to 14-day course of prednisone can be given with verapamil. When the prednisone is stopped, the dosage of the verapamil may need to be raised. Verapamil also can be combined with either lithium or divalproex.

If pharmacotherapy and histamine desensitization don't work, then surgery is a last resort. Surgeries with successful outcomes include sphenopalatine ganglionectomy and radiofrequency thermocoagulation of the trigeminal ganglion with section of the trigeminal nerve. Glycerol injection into the trigeminal cistern can also be helpful.

Stereotactic radiosurgery with a gamma knife has been used, but the results have been poor, Dr. Dalessio said.