Prophylactic Ayurveda treatment for episodic cluster headache – A Case Report

Abstract

This case is about an Episodic Cluster Headache (ECH) for 13 years treated effectively by Jaloukavacharana, Nasya and Ayurveda oral medications. It commenced with sudden episodic headache once or twice a day for a period of 40 days in a row, every year in the month of January and February. The pain intensity was 10/10 in numeric pain intensity scale, HIT -6 (Headache Impact Test) Score- 69, CHIQ (Cluster headache impact questionnaire) Score- 34 DASS 21 Scale- Depression- 8 anxiety-5 stress-11. Ayurveda treatment included one sitting of Jaloukavacharana and seven days of Kumkumadighrita Nasya. Drakshadi Kashaya, Soothashekararasa and Avipatthikara choorna were given internally. Patient reported no attacks of ECH thereafter with the HIT 6 score −36, CHIQ Score-0 and DASS-21 (Depression – 0, Anxiety-0, Stress- 0) after treatment. This line of treatment prevented the recurrence of ECH attacks with overall improvement in the quality of life without any known side effects.

1. Introduction

Cluster Headache (CH) is the most prevalent form of trigeminal autonomic cephalgia, in the primary headache category. It affects only 0.1% of the population and is extremely rare, which makes it challenging to gain insight into the disease process. Since it is among the most severe types of headaches, it is important to identify and treat it despite its rarity [1]. Most patients are episodic, with daily attacks for weeks to months, followed by remission for months to years. Any age is possible for onset, but the typical age is approximately 30 years. Men are three times more likely to suffer from this condition than women [2]. Patients reveal that they experience ten out of ten unilateral pain, most often located intra or supraorbitally. The pain is nonfluctuating and explosive in quality [1]. CH are often associated with ipsilateral lacrimation, redness of the eye, stuffy nose, rhinorrhea, sweating, and pallor [3]. Attacks typically last anywhere from 15 minutes to 3 hours. They can occur up to eight times a day, although most commonly, patients experience attacks twice daily, usually at night [4]. 15–20% of patients will have chronic cluster headaches, 10–20% of which will develop drug resistance. Patients can experience detriments to their mental health. There will be physical burdens and loss of quality of life. Many patients describe suicidal ideation, but actual follow-through action is rare [1]. The available evidence indicates that CH is a lifetime condition for the majority of patients, progressing from episodic to chronic CH in one out of ten patients and from chronic to episodic CH in one out of three patients [5]. There are two sides to the treatment of cluster headaches: treatment of acute attack and preventative treatment. 100% oxygen therapy is probably the most well-known method of treating cluster headaches. Unfortunately, oxygen therapy for those with cluster headaches—which can be challenging to obtain—is sometimes not covered by insurance. The only other level A indicated therapy is triptans. These medications can be administered subcutaneously as sumatriptan or as zolmitriptan given by nasal spray [1], however triptan adverse effects are more frequently recorded [6]. Since the onset period of oral medications, in whatever form, is frequently longer than the headache, they are not advised. Other treatments include octreotide, ergotamine, and intranasal lidocaine (with a reported 33% response). Unfortunately, medication resistance develops in 10%–20% of people with severe cluster headaches [1].

In Ayurvedic treatises, CH can be referred to as Ardhavabedhaka (Hemicranial headache SAT-D.903) under the heading of Shiroroga (∼Diseases connected to the Head area). According to Acharya Sushruta, Ardhavabhedaka is a Tridoshajavyadhi (Diseases caused by all the three humours), which is an illness in which Vata, Pitta, and Kapha are all involved with the headache attacks that tend to repeat every 10 days, 15 days, 30 days or suddenly. Acharya Charaka refers to it as a Vata-kaphaja Vyadhi that presents with pricking type of pain in half of the head, eye, eyebrow, temple region. The pathogenesis of Ardhavabhedaka involves both Rakta (blood) and visible Pitta lakshanas (signs of Pitta) [7]. Raktamokshana (Bloodletting), Samshodhana (Panchakarma-Bio-purificatory Techniques), with special emphasis on Kaya Virechana (Therapeutic Purgation), nutrition control, and lifestyle modification are all part of the therapy plan [8]. Also more than 20% of the cluster headache are associated with nausea and vomiting [9] that frequently correspond with Amlapitta (state of hyperacidity) as per our classics where nausea and headache are few of its presenting symptoms. Taking all this into consideration and also based on the clinical presentation, this case was treated effectively in accordance with Ardhavabhedaka and Amlapitta line of treatment.

2. Case presentation

We present a case of 28 years old male complaining of episodic cluster headache on the right side, each lasting for 30–45 mins once or twice a day for 40 days in a row, every year in the month of January and February for the past 13 years associated with lacrimation in right eye, nausea and vomiting during the attacks of headache. The pain intensity was 10/10 in numeric pain intensity scale. The pain would suddenly shoot up between 1am and 3am with intolerance to the light and sound. It used to subside on its own within 45 minutes. He was prescribed with flunarizine 10 mg for 3 months as prophylaxis and during acute headache attacks, he was advised with Vasograin- 1mg tablet, Paracetamol- 650mg, Diclophenac- 75mg IM injections and Sumatryptin 100mg. Not finding much relief, instead noticing rebound phenomenon, he chose Homeopathy treatment which he found temporary relief for a period 2 years during which the headache attacks were present but with lesser intensity. Thereafter he underwent a course of Ayurveda medications for 3 years and found mild relief in head ache attacks but the episodes were present as usual in that stipulated month. He being a surgeon by profession found very difficult to cope up his professional activities as this Episodic Cluster headache attacks appeared during the day time too since past 5 years. This hampered his routine badly and hence seeking better treatment he approached our OPD. None of his family suffered with similar complaints. Past medical history with symptoms, Month and year of ECH with intervention is depicted in Table 1.

Table 1.

Depicting the medical history with timeline of events.

Year/month	Events	Treatment
2010/January–march	First attack of Headache on the right side for a duration of 40 minutes twice a day associated with lacrimation in right eye, nausea and vomiting during the attacks of headache. The pain intensity was 10/10 in numeric pain intensity scale. The pain would suddenly shoot up between 1am and 3am with intolerance to the light and sound. It used to subside on its own within 45 minutes.	Flunarizine 10 mg × 3 months
2011–2013	Diagnosed as episodic cluster headache
2014–2017	Severe attacks of episodic cluster headache in the month of January and February.	Symptomatic treatment with Vasograin – 1mg, Paracetamol- 650mg, Diclophenac injections 75mg IM and Sumatryptin 100mg
2018–2020	Mild to moderate headache attacks in the month of January and February	Homeopathy treatment (Prophylaxis)
2021–2022	Mild to moderate headache attacks in the month of January and February	Ayurveda treatment (Prophylaxis)

3. Clinical findings

3.1. Local examination

• •No Frontal, ethmoidal and maxillary sinus tenderness present.
• •Since the patient was evaluated in the Remission period, there was no conjunctival congestion/lacrimation, Ptosis, Eyelid edema and Nasal congestion.

3.2. Investigation

• •MRI of brain with venogram report suggest no significant abnormality.

3.3. Dasha vidha pareeksha

• 1.Prakruti (physical constitution): Pitta vata
• 2.Vikruthi (morbidity): Vata dosha dominant Tridohsa
• 3.Sara (excellence of dushya or tissue elements): Madhyama (Moderate)
• 4.Samhanana (compactness or tissues or organs): Madhyama
• 5.Pramana (measurement of body constituents): Madhyama
• 6.Satmya (homologation): Ahara Satmya (food homologation)
• 7.Satva (psycic condition): Pravara (good)
• 8.
  Aahara Shakti (power of intake of food): Madhyama

  • Jarana Shakti (power of digestion of food): Avara (poor)
• 9.Vyayama Shakti (power of performing exercise): Madhyama
• 10.Vayah (age): Madhyama

4. Diagnostic assessment

• 4.a Nidana ((etiologyetiology) Raatrijagarana (Staying awake in the night), Divaswapna (sleeping during the day time), Exposure to hot climate, excessive spicy and sour food consumption

• 4.bPurvaroopa (prodromal symptoms) Nothing specific

• 4.cRoopa (signs and symptoms): Severe pricking and churning pain in one half of the head specifically involving eyebrow, temporal region, and forehead region of the affected side. Visual impairments when the disease is in the aggravated state.

• 4.d Samprapti (pathogenesis):

  • a.
    Dosha (regulatory functional factors of the body) – Vata- Prana (vitiated due to nidana like raatrijagarna)
  • Pitta- Pachaka (vitiated due to causitive factor like hot climate, excessive spicy and sour food consumption)
  • Kapha- Sleshaka (vitiated due to the causitive factor like day time sleep)
  • b.
    Dushya (tissue elements)- Rasa, Rakta
  • c.
    Srotas (structural or functional channels)- Rasavaha, raktavaha
  • d.
    Marga-Madhyama
  • eQ3: Table 2 was/were not cited in the text. Please check that the citation(s) suggested are in the appropriate place, and correct if necessary. (see. )
    Table.2Ama-Vidagdham (due to amlapitta like symptoms)
  • f.
    Udbhavasthana-Amapakwashaya (gastrointestinal tract)
  • g.
    Sanchara sthana-Sarvashareera (permeating the whole body)
  • h.
    Vyakta sthana-Shiras (head)

• 4.eUpashaya (relieving factors) Gets temporary relief with consumption of medicines.

• 4.f Vyavachedaka Nidana (differential diagnosis of cluster headache) [10].

• 4.g Vyadhi Vinischaya (diagnostic criteria) [11]:

Table 2.

Depicting the differential diagnosis of cluster headache.

	Cluster headache	Paroxysmal hemicrania	aSUNCT	Hemicrania Continua
Attack duration	15–180 min	2–30min	5–240sec	20 mins- days
Attack frequency	1 Alternate days-8/day	5-40/day	3-200/day	–
Chronic/Episodic	Episodic	Chronic	Chronic	Chronic
Characteristics	Restless during attacks	–	Triggered and spontaneous attacks	–
Prophylactic Treatment	Verapamil, Corticosteroids, Lithium	Indomethacin, Rofecoxib	Carbamazepine, Gabpentin, Lamotrigine	Indomethacin, Rofecoxib
Sex Ratio (Male: Female)	3:1	1:2	2:1	1:2

^aShort-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing.

4.1. Episodic cluster headache

• 1.Five attacks per day with unilateral orbital pain lasting upto30-45mins
• 2.Unilateral conjunctival injection or lacrimation
• 3.Sense of restlessness or agitation
• 4.15 Cluster periods lasting for 40 days separated by pain free remission period of 10–11 months.
• 5.Occurring with daily frequency for a period of 40 days

4.2. Intensity and severity scale

• CHIQ [12]- 34

• HIT-6 [13]- 69

• DASS-21 [12]- 26

• Headache related disability based on HIT 6 [12] - Severe

• VAS- 10

5. Timeline

Timeline of events has been depicted in Table 3.

Table 3.

Depicting the timeline of the events.

Year/month	Events	Treatment
2010/January–March	First attack of Headache on the right side for a duration of 40 minutes twice a day.	Flunarizine 10mg × 3 months
2011–2013	Diagnosed as episodic cluster headache
2014–2017	Severe attacks of episodic cluster headache in the month of January and February.	Symptomatic treatment with Vasograin – 1mg, Paracetamol- 650mg, Diclophenac injections 75mg IM and Sumatryptin 100mg
2018–2020	Mild to moderate headache attacks in the month of Januray and February	Homeopathy treatment (Prophylaxis)
2021–2022	Mild to moderate headache attacks in the month of January and February	Ayurveda treatment (Prophylaxis)
1-12-2022	Remission period	Leech therapy x 1 sitting
2-12-2022 to 8-12-2022	Remission period	Marsha Nasya x 7 days
9-12-2022 to 8-06-2023	Remission period	Pratimarsha Nasya x 6 months Oral medicines 3–6 months
09-06-2023- 5-10-2023	Remission period	No medications
6-10-2023- 31-10-2023	Moderate – severe attack Got treated under a neurologist	1.Verapamil 80 mg TID for 2 weeks 2.Naproxen 500mg + Sumatriptan 85mg tablet BD x 3 days 3.Esomeprazole 40mg Tablet bd x 10 days 4.O2 12L/min 5.Prednisolone 20mg tablet 1-1-0 x 3days 6.Prednisolone 20mg tablet 1-0-0 x 3 days 7.Prednisolone 20mg tablet 1/2-0-0 x 2 days
30-11-2023	Remission period	Leech therapy x 2nd sitting for 20 minutes
1-12-2023 to 1-1-2024	Remission period	Kumkumadi Ghrita Pratimarsha nasya x 1 month
2-1-2024 to 4-4-2024	Remission period	Stopped all medications.

6. Therapeutic intervention

Ayurveda treatment given is depicted in Table-4.

Table 4.

Depicting the treatment administered in detail.

S.no	Treatment	Dose	Duration	Timeline
1.	Leech therapy	–	One sitting for 25 mins over the right temporal region	1-12-2022
2.	Nasya with Kumkumadi ghrita by the therapist. (Yenepoya Ayurveda teaching pharmacy, Mangalore)	3ml (6 Bindu) to each nostril	Every Morning for 7 days	2-12-2022 to 8-12-2022
3.	Soothashekhara rasa tablet (Manufacturer: Dhootpapeshwar, Maharashtra, India)	250 mg thrice daily with lukewarm water	3 months	9-12-2022 to 8-03-2023
4.	Pratimarshanasya with Kumkumadi Ghrita done by the patient during follow up period.	Two bindu (1ml) instilled into each nostril thrice daily	Day eight to the end of 6 months	9-12-2022 to 8-06-2023
5.	Drakshadi Kashaya (Manufacturer:Nagarjuna, Kerala, India.)	15ml tid before food	3 months	9-12-2022 to 8-03-2023
6.	AvipatthikaraChoorna (Manufacturer:Nagarjuna, Kerala, India)	5 gms	Once daily at night for 6 months	9-12-2022 to 8-06-2023

7. Pathyapathya

Patient was advised to avoid spicy, sour foods, non-vegetarian foods, caffeinated drinks, and carbonated drinks. And was asked to incorporate foods such as green gram, cow's ghee, dates and milk in his regular diet. Life style modification such as avoiding alcoholics beverages, maintaining a proper sleep schedule and avoid over exposure to sunlight was advised.

8. Treatment outcome and follow up

Treatment outcome is portrayed in Table 5.

Table 5.

Showing the treatment outcomes in individual Parameter with the timeline.

S.no	Test	Before treatment	Timeline	After treatment: Episodic cluster headache month (January–February 2023)	Timeline
1	HIT -6	69 (Severe impact)	01-01-22 to 10-2-2022	36 (Mild or no impact)	01-01-2023 to 5-10-2023
2	DASS-21
	Depression	8 (Moderate)	01-01-22 to 10-2-2022	0	01-01-2023 to 5-10-2023
	Anxiety	5 (Mild)	01-01-22 to 10-2-2022	0	01-01-2023 to 5-10-2023
	Stress	11 (Moderate)	01-01-22 to 10-2-2022	0	01-01-2023 to 5-10-2023
2	VAS	10	01-01-22 to 10-2-2022	0	01-01-2023 to 5-10-2023
3	CHIQ	34	01-01-22 to 10-2-2022	0	01-01-2023 to 5-10-2023

Patient had no attacks of headache in the tentative month of ECH (January–February 2023) as appeared during the past 13 years. He was on oral medications for 6 months until June 2023 and a follow up period of 3 months where in cessation of all medications were done. No adverse events found throughout the treatment course and thereafter during follow up. On October 6th, 2023, post hectic work schedule, improper and untimely food consumption patient had an attack of ECH which continued till October 31, 2023. This Attack of ECH lasted for 25 days when compared to previous attacks that lasted for 45 days.

9. Discussion

Cluster headaches have a complex etiology, and the underlying mechanisms are still poorly understood. CH is a neurovascular rather than a vascular headache, with vascular cerebral alterations being triggered by the activation of the trigeminal-autonomic reflex [14]. According to a theory put up by Ansari et al., the anti-inflammatory and analgesic compounds found in leech saliva may have the ability to inhibit Trigeminal vascular system and so diminish the release of Calcitonin gene related peptide from neurovascular terminals, which would then cause the analgesic effect [15]. Also a study conducted by Michalsen et al., states that the analgesic effect of single sitting of leech therapy lasts up to 2 months [16] that might have helped in prevention of the episodic cluster headache in this case.

Using intranasal drug administration to reach the central nervous system through the respiratory and olfactory pathways is a promising strategy. Positively charged, smaller molecular weight lipid-based medications with a molecular weight between 400 and 600 Da (Dalton) are better able to pass the blood-brain barrier [17]. Saffron is traditionally known to ease pain. Its analgesic activity was evaluated in vivo and in clinical trials [18]. Nordin et al., 1977 concluded that cluster headache attacks are associated with an increase in MSA (Muscle nerve sympathetic activity) that elevates blood pressure by causing vasoconstriction [19]. Recent study conducted by Llorens et al.,2015, have reported that crocetin exhibits potent vasodilator effects on isolated aortic rings from hypertensive rats [20]. Hence the rationale behind opting Kumkumadi Ghrita [21] for Nasya was its indication in Pittaja and Raktaja Shirorogas (Diseases of head) and also considering the patient's age (Madhyama Vaya (Middle aged), and Pitta aggravating factors in causing the disease. Kumkumadi Ghrita when administered through nasal route prophylactically, owing to its analgesic activity, might have prevented the attacks of headache.

In addition, there was a strong co existing symptoms like fatigue, vomiting, nausea along with the episode of cluster headache. Ayurveda emphasizes on the meal when putrefies in the bowel due to improper digestion, gives rise to Vata Vikruti and Rasa-Rakta Dusti. This in turn results in the production of several diseases and one among them is Ardhavabhedaka. The best course of treatment for such disorder arising due to improper digestion is Sutashekhara rasa which is having, Vedanasthapana (pain relieving properties), Deepana (enhancing metabolic fire), Pachana (digestion), and Tridosha shamaka karma (pacifying the three bio-humours). [22] Drakshadi Kashaya owing to its property of pitta and Vata shamana [23] might have rectified the Amlapitta like symptoms in this case. Virechana is one among the line of treatment in Ardhavabhedaka and hence Avipatthikara choorna [24] when administered on daily basis would have acted in bringing off Koshta shuddi (bowel cleansing action). Also, Avipatthikara choorna is a drug of choice in Amlapitta that might have helped to restore the acid alkali balance and enhanced the digestive system's ability to function thereby preventing further episodes of headache.

We could infer that Ayurveda prophylaxis treatment approach was effective in preventing and prolonging the episodic attacks of cluster headache with no known side effects and showed considerable improvement in this patient's quality of life in terms of sleep, food intake and psychological stress. Most importantly we could prolong the attacks of episode of Cluster headache and reduce the duration and intensity in the ECH attack that appeared once thereafter.

10. Conclusion

Ayurveda treatment is beneficial and safe in providing maximum recovery in cluster headache. Cluster headache is one such disorder hampering the quality of life and hence should be treated effectively. This approach could be implemented on larger samples of not only cluster headache but other forms of migraine too in the near future. Effectiveness of this treatment protocol could be adopted and evaluated during the acute attacks of cluster headache episodes too. Also, the duration of treatment in remission period to be standardized in preventing the next attacks of ECH.

Patient perspectives

Patient self-reported that he was very much satisfied with the treatment and had no episodes of headache attacks during the tentative cluster headache months after the course of our treatment. This in turn improved his quality of life by considerable reduction in his mental stress. Patient could perform all his professional duties without any fear of impending headache attacks. Episodes of cluster headache appearance was prolonged for 10 months and the attack which came then had shorter duration and was not too severe as in previous years.

Informed consent

Patient has given written consent for publishing his case report in the journal. Patient is also aware that his name and personal data will not be published and due efforts will be made to conceal the identity.

Source of funding

None.

Declaration of generative AI in scientific writing

None.

Author contributions

AKB and VKK contributed in conceptualization, study design, writing and reviewing the manuscript.

Conflict of interest

All the authors declare no conflict of interest for the manuscript titled Effective prophylactic Ayurveda treatment in successfully preventing an attack of Episodic Cluster headache– A Case study.

Appendix A. Supplementary data

The following are the Supplementary data to this article.