The Suicide Headache:
Cluster Headaches 

The sun rises over the San Joaquin Valley, California, today is March 18, 2020. Last week marked the 5thanniversary since we opened our home at East Niles Community Health Center. The grand opening was on March 6, 2015. Also, Match Day 2020 is coming soon! We are happy to inform that we matched all 8 positions. We will know the residents’ names in a few days. This will be our 6th class. We are excited to welcome a new group of motivated residents starting in June 2020.  

Also, COVID-19 has infected over 200,000 and caused almost 9,000 deaths worldwide. A few hours ago, a non-resident in Kern County was confirmed to be positive for coronavirus(1). This pandemic continues to evolve every day, but we will not talk about it any further today. Visit the CDC website, or contact your local public health department for accurate and updated information.

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“If you think education is expensive, try ignorance.” (Unknown author, possibly Ann Landers)

Headache is among the top 10 chief complaints among primary care visits, we are happy to address this relevant topic with one of our chief residents. Today our guest is Lisa Manzanares. Lisa is on her third year. I am pleased to see you today. By the way, she has also been the voice of our “Speaking Medical” section. How are you doing today?

You know we ask 5 questions in this podcast. We’ll start with the first question.

1. Question number 1: Who are you?

You want the short or the long answer? I have to talk for 20 minutes they say, so you’re getting the ‘long.’  I’m a U.S. Navy veteran, mom of 3 little girls, a wife, a rock climber, explorer of the Sierras, a long board enthusiast, and a ….right, and a third year family medicine resident in the Rio Bravo Family Medicine Program.  I took the circuitous route here: after graduating medical school in 2013 from Western University of Health Sciences in Pomona, CA, I did an Intern year at Naval Medical Center San Diego. After that, the Navy sent me to the Central Valley where I practiced outpatient general medicine.  I took care of Active Duty members and their families while stationed at the Naval Hospital in Lemoore.  

Comment: What a nice bio, we are happy to have you as one of our residents. 

1. Question number 2: What did you learn this week?

I learned about the acute treatment cluster headaches in the clinic. 100% oxygen via nonrebreather facial mask with flow of at least 12L/min.   You should continue x 15 minutes to prevent the attack from returning, though the patient may feel better in as little as 5 minutes.  As for medications: subcutaneous sumatriptan 6mg is beneficial in about 75% of patients, intranasal sumatriptan  or zolmitriptan can also be used but is slower in onset.  Sometimes only 3mg sumatriptan SQ can benefit patients.  Intranasal triptans are administered CONTRALATERAL to the pain side, because patients with cluster headache often have rhinorrhea and congestion on the side ipsilateral to the pain, impeding the delivery of the medication.  Intranasal lidocaine in a 4-10% solution can also be used, and is effective in about 1/3 of patients.  The lidocaine is administered on the IPSILATERAL side. 

Comment: We may not see the patient during the acute pain, but if you see a patient with acute cluster headache this is the treatment that needs to be given. Some patients have chronic cluster headache without remission periods.

Cluster headache is more prevalent in men and typically begins between 20 and 40 years of age. Trigeminal autonomic cephalgia: Unilateral, located on the temporal or periorbital area, accompanied by at least one ipsilateral symptom in the eye, nose, or face (rhinorrhea, conjunctival injection); it causes restlessness or agitation, duration of 15 to 180 minutes, One episode every other day to eight episodes p