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 per day. It is a severe headache(2). 

One of my patients explained it to me in a very painful way. He put a pen on his eye and stabbed himself on the eye, thankfully he only injured the medial aspect of his eye lid, but you can tell how intense the pain is if your patient is willing to stab himself in the eye to describe it.

Prophylaxis:As for prophylaxis of cluster headache, verapamil is the first-line therapy. Other meds that aren’t 1st line but may work: glucocorticoids, lithium, topiramate; more invasive treatments such as nerve stimulation and surgery may be helpful in refractory cases.

1. Question number 3: Why is that knowledge important for you and your patients?

Cluster headaches are miserable.  In fact, the pain is described as a severe ‘suicide headache’ under diagnostic criteria in journal articles on cluster headache. My job as a family physician is to reduce common miseries.  About 1 in 1000 US adults has experienced a cluster headache, and cluster headache has a large associated morbidity: 80% of these patients report restricting daily activities. Common + miserable =something we need to learn about for the sake of our patients. Plus, oxygen is something that is in every clinic. This is one way to be able to treat the patient on the spot, and have them walking out of the clinic feeling better.

Comment: Tell us about the triggers of cluster headaches.

Triggers include vasodilators (e.g., alcohol, nitroglycerin) and histamine, tobacco exposure (first hand or second hand)

1. Question number 4: How did you get that knowledge?

There’s always that question about 100% oxygen and cluster headaches on the boards, on shelf exams.  This is probably not news to anyone listening to the podcast. So the oxygen thing was something that actually stuck from med school.  

In terms of finding out more of what to do with the patient, how to make her feel better, I had to look some stuff up.  

My trusty sources in clinic are 1.) Up to Date and 2.) Faculty.  3.) Review/Journal articles. Not necessarily in that order.  

1. Question number 5: Where did that knowledge come from?

The info is an amalgam of: knowledge from Dr. Schlareth, our faculty member here, “Cluster Headache” by Dr. Weaver-Agostoni downloaded from the AAFP website, and “Cluster Headache: Treatment and Prognosis” on Up-to-Date(3). See details in our website.

Now we conclude our episode number 3 “The Suicide Headache”. Cluster headache is no joke. When you encounter a patient with a cluster headache, remember to use oxygen and abortive treatment as explained before. Do not forget to prescribe prophylaxis treatment if indicated.

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Speaking Medical (Medical word of the Day) 
by Monica Kumar, MD

Hi, my name is Dr Kumar, today I want to teach you the medical word of the day. Since everyone is fighting over toilet paper, we thought it was only appropriate to introduce to you the explosive medical term of the week. Steatorrhea. “Steatorrhea” is the excess of fat in the stools often due to the impaired transport of nutrients across the apical membrane of the enterocytes, that results in oily, foul smelling stools.

Some of the underlying causes of steatorrhea are celiac disease, cystic fibrosis, pancreatitis, lactose intolerance and gastrointestinal infections. 

If you see a patient with steatorrhea (not caused by the consumption of unhealthy amounts of burger and fries), please investigate further by asking onset, duration, frequency, triggers, and travel history, perform a complete physical exam, and order additional studies based on your assessment.  In young children presenting with failure to thrive and steatorrhea, do not forget about cystic fibrosis. 

Remember the medical word of the day steatorrhea.

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Espanish Por Favor (Spanish Word of the Day) 
by Greg Fernandez

Welcome to your section Espanish Por Favor, this is Dr Fernandez and today’s Spanish word of the day which is “Piquete”. “Piquete” is translated as a prick, shot, jab, injection or a stinging pain or discomfort. The scenario where someone would use this word would sound like this: “Doctor, me da un piquete en el pecho” or “Doctor, tengo piquetes en las piernas”. 

It means “Doctor, I have a shot-like pain on my chest” or “Doctor, I have pricks on my legs.”  People can use this word to refer to an acute, sudden, short-duration, stinging, sharp pain. It is like a “bird bite”. The etiology of this pain can be very broad and can include muscle spasms, neuropathy, leg cramps, or many other conditions. It may also be a sign of no disease at all. Now you know the Espanish word of the day, “piquete”. 

All you have to do is go and assess your patient’s “piquetes”. That’s all for today, have a great week, and remember to wash your hands, avoid touching your face and avoid crowded places. Thank you.  

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For your Sanity (Medical joke of the day)
by Simron Gill, MS4 and Monica Kumar, MD

--Why did the teacher with tertiary syphilis get fired? 

--Why?

--He couldn't control his pupils

--What is an EKG finding of hypospadias? 

--It doesn’t make sense, what does an EKG shows in hypospadias?

--Inverted P waves 

Duck Hunting 

A family medicine doc, an internist, a surgeon, and a pathologist are out one day duck hunting. 

First up is the family doc, he raises his gun to take aim at a flock of birds passing overhead and says to himself, "It looks like a duck, flies like a duck, quacks like a duck, it must be a duck." BANG! He bags himself a duck.

The internal medicine doctor then steps up, raises his gun to take aim at a second flock of birds flying overhead. He says to himself, "Looks like a duck, flies like a duck, quacks like a duck, rule out quail, rule out pheasant, goose versus duck likely." BANG! He, too, bags himself a duck.

A third flock of birds then flies overhead and the surgeon steps up and raises his gun at the flock. BANG! BANG! BANG! BANG! BANG! He fires multiple rounds at the flock and dead birds are dropping all around. The surgeon lowers his gun, walks over to one of the dead birds, picks it up, hands it to the pathologist and says, "Tell me if this is a duck."

References:

1. The Bakersfield Californian, Non-resident tests positive for coronavirus in Kern County, https://www.bakersfield.com/news/non-resident-tests-positive-for-coronavirus-in-kern-county/article_618b45b2-686c-11ea-ab78-e70420b5c2fd.html , accessed on March 17, 2020.
2. Jacqueline Weaver-Agostoni, DO, MPH, University of Pittsburgh Medical Center Shadyside Hospital, Pittsburgh, Pennsylvania. Am Fam Physician. 2013 Jul 15; 88(2):122-128. https://www.aafp.org/afp/2013/0715/p122.html#afp20130715p122-t1
3. Arne May, MD,  Cluster headache: Treatment and prognosis, Up to Date, https://www.uptodate.com/contents/cluster-headache-treatment-and-prognosis?search=cluster%20headache%20treatment&source=search_result&selectedTitle=1~72&usage_type=default&display_rank=1, accessed on March 17, 2020.