Geerlings (2011) Rebound following oxygen therapy in cluster headache
Abstract
Background: Rapid recurrence of a new cluster headache attack following oxygen treatment was named the ‘rebound effect’ by Kudrow (1981). It has never been studied properly. To study this effect, we defined it as a more rapid than usual (for the individual patient) recurrent cluster headache attack after complete relief following oxygen therapy, or an increase in the number of attacks per 24 hours while using oxygen therapy as acute attack treatment. We reviewed the literature and searched our cluster headache study databases.
Case series: In our eight patients with rebound cluster headache, the effect was experienced following 87.5% of oxygen treated attacks. Duration until the next cluster headache attack was on average 894 minutes shorter and frequency was on average 1.6 cluster headache attacks per day higher than without oxygen therapy.
Conclusion: Although the 1981 trial reported a prevalence of 25%, rebound cluster headache following oxygen therapy is rarely reported nowadays. This may be due to better techniques in oxygen application, the use of higher oxygen flow rates or underreporting. The few literature data and data on our eight patients did not provide clues about the mech- anism of the rebound effect. Further study, applying the proposed definition, seems useful.
Dr. Sewell’s comment:
Those of you reading this blog will have noticed that I have not posted in a while… almost a year, in fact. Not that I’ve lost interest, mind you! Between the last post and this one, I bought a house, got married, and also was promoted to junior faculty at Yale Medical School, which carries with it a host of new responsibilities. I think that any one of those is reason enough for some time off! But things have settled down now, so I’m planning to start posting again.
We end the old year and start the new one with a paper by Dr. Geerlings from the Netherlands, who is interested in “rebound headaches” following oxygen therapy. Oxygen has been used to treat cluster headache since 1952, but as early as thirty years ago patients noticed that even though sometimes oxygen brought complete pain relief, when they stopped the oxygen another attack would soon begin—and in some indefinable way, they could tell it was still the same attack, suggesting that oxygen had only delayed the attack rather than curing it. This second attack was termed a “rebound headache”, and defined as a more rapid-than-usual recurrent cluster attack after complete relief from oxygen, or an increase in the number of attacks in the next day following oxygen therapy.
Dr. Geerlings searched through her database of 158 cluster headache patients and also did a literature search to see what she could find about rebound headaches. She found eight patients with rebound headaches (4%). On average, these eight experienced rebound headaches 88% of the time after using oxygen, usually 40 minutes later (as opposed to 16 hours later without oxygen), and they had more than four attacks per day when using oxygen as opposed to 2.5 attacks a day without oxygen. The literature search revealed that the only other doctor to describe rebound headaches was Dr. Kudrow, back in 1981, who found that a quarter of his patients who responded to oxygen also experienced rebound headaches. It’s hard to know why Dr. Kudrow found so many more—it’s possible that the higher flow rates used with oxygen nowadays prevent rebound headaches (four of the eight in this study used flow rates of 7 L/min or less), or maybe doctors nowadays just don’t ask! Oxygen is not the only treatment for cluster headache that can cause rebound headaches—sumatriptan (Imitrex) can also increase the severity and frequency of attacks over the next day.
What’s your experience?
Welcome back! My experience with O2 has been encouraging, but not foolproof. Thanks to new information regarding the most effective breathing methods, all but a few of my attacks are stopped completely. However, I will still experience 2-3 attacks during the peak of a cycle which are intractable. Last spring, I remember one in particular during which I used O2 four times on it, and finally gave up.
At my worst chronic years in the recent past (2004-2009) I still had 6 attacks a day – could set a watch by them. I used 12 lpm for 15 min. which usually gave me relief for a few hours. Even if that was rebound, the few hours nearly pain-free was worth it. I was frantic with pain when I started the oxygen. I was mostly pain free 2009-2010, even stopped verapamil and Topamax. But they came back less frequently and less severely. I have not had to use oxygen since last May. Verapamil 480 mg. is the only med. plus some PT for the neck pain and muscle soreness which is concurrent with the headaches. I have been diagnosed with occipital neuralgia as well as CH.
WELCOME BACK. Enjoyed attending your wedding!!
Sandi
Welcome back and thanks for the new posting!
My own experience and that of some other CH patients I know is that it requires a minimum of five (better ten) further minutes of oxygen inhalation after the pain is gone (or greatly reduced) to avoid a rebound cluster headache. These five minutes are usually (but not always) sufficient to avoid rebound of my CH hits. Some other CH sufferers say they need more additional inhalation time.
My chronic CH was diagnosed six years ago and oxygen treatment worked well for the first couple of month with a normal facial mask. Then the oxygen treatment didn’t work any more and I learned that a non-rebreather mask does a much better job. Since about Febr. 2006 I am using an optimised non-rebreather mask which was “invented” by the British CH patient Ben Khan. Some pictures of the mask can be found here:
http://www.ck-wissen.de/ckwiki/index.php?title=Clustermasx
The mask is assembled from standard respiratory care components. The advantages of this mask are that the valves work properly and that the mask body sits tight to the face. This avoids the inhalation of room air. The big reservoir bag allows for deep breathing during the CH attack, which in my opinion shortens the time needed to abort the CH attack. Ben’s Clustermasx is not available anymore, but there are some similar good products which work with the same principle. With this mask I require a flow rate of 15 liter/minute or more and CH attacks are usually gone in less than 5 minutes.
More about CH high concentration O2 masks (German):
http://springhin.de/ckmaske
With Ben’s optimised oxygen inhalation setup I have successfully treated 763 CH attacks since February 2006 without any treatment failures.
Nevertheless, even with the high flow rate, the optimised oxygen delivery system and the additional five minutes oxygen inhalation time rebound CH attacks sometimes do happen during times of CH escalation. In December 2008 my nightly CH hits returned every 1 to 2 hours after successful oxygen treatment of the previous attack. Then I started to use Frovatriptan as an additional preventive medication with good results.
One effect of the additional preventive medication with Frovatriptan is that the rebound CH hits are gone completely!
The result of my own Frovatriptan “dose finding studies” is that I, in a phase of CH escalation, take 4 x 2.5mg Frovatriptan per day (one tablet every six hours) and on average have only one CH hit in 24 hours.
For me there are cardiologic problems with increasing the Verapamil dose, that is the reason why we use the Frovatriptan as an additional preventive medication. Probably adjustments of the preventive medication would help other CH patients to avoid O2 rebound CH?
Oxygen is tricky, but once you get it down, it can be affective almost every time. Batch from the CH.com board has given great advice on O2 therapy. Flow rates @ 15 lpm or higher is suggested and once you feel relief, stay on the O2 for an additional 5 minutes at a lower flow rate (8-10 lpm) to make sure it doesn’t come back. I have also found after a quick abort with O2, I chug 1 pint of an energy drink with 1000mg of taurine. That’s like the KO for me. I agree though that O2 can cause rebound HA’s if it is not used correctly. I haven’t used A Triptan in over 3 years thanks to O2 therapy.
Ben gave me one of his Clustermasx some years ago and I have it sitting in my desk drawer beside me right now. I never quite understood why it was supposed to work better than regular masks, so I thank you for the explanation. I have heard plenty of positive testimonials from cluster headache patients who have used it, but as far as I know there have been no head-to-head trials with Clustermasx versus regular masks. However, I’m sorry to hear that he’s stopped making it.
Compared to the standard O2 masks the Clustermasx and it’s copies have a reservoir bag with a sufficient size and they close tight to the face. This avoids the inhalation of room air and results in a higher oxygen concentration in the lungs. Perhaps that’s the reason why many CH patients have better results with the Clustermasx.
Dr. Todd D. Rozen is doing a study with high flow O2 rates using demand valves at the Geisinger Clinic: http://clinicaltrials.gov/ct2/show/NCT01298921
I enjoyed your helpful blog. awesome stuff
My view has always been that O2 alleviates the pain. It does not abort a headache. I think the use of O2 for the length of time of a headache would usually take means that the pain is alleviated but the process still goes on. That is why if the use of O2 is too short the pain will return. My experince with CH is getting the timing of treatment right which is the tricky bit and has a psychological component. (How long you leave something before you act) I am always hopeful that when pain does not escalate it can mean remission.
For me the time of pain escalation equals the time it takes to alleviate. Leaving the pain too long means a point of no return and no alleviation. ET.
I have heard it said by patients (although I don’t know how true it is) that each cluster attack is subtly different, so it is possible to tell when one attack dies away with oxygen then comes back, as opposed to a second attack starting independently over the time period. In contrast, attacks from paroxysmal hemicranias appear to be more stereotyped, so it is not possible to distinguish between two separate attacks and one that comes and goes.
My experience is that if I use O2 when I have a shadow(s). To explain further my shadows are relatively constant. I have become used to them over a lifetime. Not all develop into high level pain. In times of remission I still have them most days but can ignore them as they are part of my life.
In cycle if I stop using O2 while the shadow is still present then it remains and develops. If I stay on O2 for a further 20 to 30 minutes after the shadow is gone it usually means I am pain free for a while. However, at the peak of a cycle, I am on O2 every hour because i dont know what will develop or not. To be honest I do notice a difference in attacks but it is generally in different cycles not each attack in one cycle. Mind you whilst in cycle subjectivity takes over.
The cluster masx is as Friedrich says really good – fast and effective but I have modified this to a pedal bin bag size bag as it is it is more efficient. Use of it for 10mins after the attack is really importantg to reduce the incidence of the HA reoccurring now all they need to invent is a way to turn it off when you fall asleep/pass out.
i hav suffered ch for over 30yrs & got onto o2 nine yr ago. i can confirm that o2 use has caused rebound ch in my case, but at least i can generally reduce their intensity most times. The number of attacks per day has increased many fold with o2 use compared to the many yrs i had them without o2 use. It is still a life saver for me. Regards Neil