Dr. Steven Sykes: Unraveling Cluster Headaches

A board-certified neurologist talks about cluster headaches

In this episode of Ira's Everything Bagel Podcast, host Ira Sternberg sits down with Dr. Steven Sykes, a renowned board-certified neurologist with a specialty in clinical neurophysiology. Practicing at Cedars-Sinai Medical Group in Santa Monica, California, Dr. Sykes is an expert in diagnosing and treating complex neurological conditions. This week’s conversation delves into the intricacies of cluster headaches, a debilitating condition often overshadowed by the more commonly known migraine headaches. With his extensive background in neurology, Dr. Sykes provides invaluable insights into the causes, symptoms, and treatment options for cluster headaches, highlighting the latest advancements in neurological care.

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Cluster Headaches: An Overview

What Are Cluster Headaches?

Cluster headaches are often described as one of the most painful conditions a person can experience. Unlike migraines, which can last for hours or even days, cluster headaches occur in cyclical patterns or “clusters,” usually lasting for a period of weeks or months. In this episode, Dr. Steven Sykes explains the critical differences between cluster headaches and migraines, emphasizing that while both are severe, cluster headaches are typically shorter in duration but more intense. Dr. Sykes notes that recognizing the non-headache symptoms, such as eye redness, nasal congestion, or eyelid drooping, can be crucial in differentiating between the two.

Genetic Factors and Diagnostic Testing

One of the key points discussed in the podcast is the genetic predisposition to cluster headaches. Dr. Sykes explains that while the exact cause of cluster headaches remains unknown, there is evidence to suggest that genetics play a role in increasing the risk of developing this condition. He discusses the importance of diagnostic testing in establishing an accurate diagnosis, which often includes a combination of patient history, physical examination, and neuroimaging studies. Dr. Sykes emphasizes that accurate diagnosis is essential for determining the most effective treatment plan.

Treatment Options for Cluster Headaches

Acute and Preventative Treatment Strategies

For those suffering from cluster headaches, finding effective treatment is paramount. Dr. Steven Sykes outlines the various acute (or rescue) treatment options available, which aim to provide immediate relief during a headache attack. One of the most effective treatments, according to Dr. Sykes, is the administration of oxygen at a high flow rate. This treatment is particularly beneficial as it can provide rapid relief without the side effects commonly associated with medications.

In addition to acute treatments, Dr. Sykes also discusses preventative treatment strategies designed to reduce the frequency and severity of cluster headache episodes. Some of these treatments are borrowed from the migraine world, including certain medications that have been found to be effective in preventing cluster headaches. Dr. Sykes provides detailed information on how these treatments work and the importance of tailoring them to the individual needs of each patient.

The Impact of Cluster Headaches on Personality

How Prolonged Episodes Affect Patients

Living with cluster headaches can have a profound impact on a person’s life, not only physically but also psychologically. Dr. Steven Sykes talks about the impact of prolonged cluster episodes on the personality of patients, noting that the chronic pain and unpredictability of the attacks can lead to significant emotional and mental health challenges. He stresses the importance of a comprehensive treatment approach that addresses both the physical and psychological aspects of the condition. Dr. Sykes also shares his insights on how establishing a strong doctor-patient relationship can help in managing the condition more effectively.

Understanding Cluster Headaches: A Doctor's Perspective

What Can Help Establish a Diagnosis

Establishing an accurate diagnosis is often the first step towards effective treatment. In the podcast, Dr. Steven Sykes discusses the various factors that can help a doctor establish a diagnosis of cluster headaches. He emphasizes the importance of thorough patient history and understanding the pattern of the headaches. Dr. Sykes also highlights the role of advanced imaging techniques and other diagnostic tools in ruling out other potential causes of the symptoms. His approach underscores the importance of a detailed and methodical process in diagnosing neurological conditions.

Dr. Steven Sykes: A Leader in Neurology

Professional Background and Expertise

Dr. Steven Sykes is not only a highly skilled neurologist but also a respected leader in his field. He currently serves as the chief of the Division of Neurology for the Cedars-Sinai Medical Group and holds the position of assistant clinical professor in the Department of Neurology at Cedars-Sinai Medical Center. His extensive training includes a medical degree from the University of Michigan, a neurology residency at the University of California at Los Angeles (UCLA), where he served as chief resident, and a fellowship in clinical neurophysiology at the University of Southern California (USC). Additionally, Dr. Sykes is board-certified in the subspecialty of clinical neurophysiology through the American Board of Psychiatry and Neurology.

Cedars-Sinai Neurology Department

Cedars-Sinai Medical Center is renowned for its cutting-edge neurological care, and Dr. Steven Sykes is at the forefront of this field. The Cedars-Sinai Neurology Department offers a comprehensive range of services, from diagnosis to treatment, for patients with various neurological disorders. As part of a world-class medical group, Dr. Sykes and his colleagues are dedicated to providing the highest standard of care to their patients, utilizing the latest technologies and treatment protocols to ensure the best possible outcomes.

For more information about the Cedars-Sinai Neurology Department, you can visit their official website.

Dr. Steven Sykes, MD, Podcast Episode Conclusion

This episode of Ira's Everything Bagel Podcast provides listeners with an in-depth understanding of cluster headaches and the challenges faced by those who suffer from this condition. Dr. Steven Sykes offers expert insights into the causes, symptoms, and treatment options available, emphasizing the importance of early diagnosis and personalized care. His discussion also sheds light on the broader field of neurology and the advancements being made at Cedars-Sinai Medical Center.

For those interested in learning more about Dr. Steven Sykes and his work, or to stay updated on the latest in neurological care, be sure to follow Cedars-Sinai on their social media platforms:

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FAQS About Dr. Steven Sykes, MD

Who is Dr. Steven Sykes, MD?

Dr. Steven Sykes, MD, is a board-certified neurologist who specializes in the diagnosis and treatment of neurological disorders. He is known for his expertise in managing conditions such as epilepsy, migraines, and neurodegenerative diseases. Dr. Sykes has a strong academic background and is affiliated with several prestigious medical institutions.

What is DR. Steven Sykes know for?

Dr. Steven Sykes is known for his contributions to the field of neurology, particularly in the treatment of epilepsy and other seizure disorders. He is also recognized for his research in neurodegenerative diseases and his commitment to advancing neurological care through innovative treatment approaches and patient education.

How old is Dr. Steven Sykes?

The exact age of Dr. Steven Sykes is not publicly available. However, based on his years of experience and professional standing, he is likely in his late 40s to early 50s.

Is dr. Steven Sykes Married?

There is no publicly available information regarding Dr. Steven Sykes' marital status. Like many medical professionals, Dr. Sykes maintains a private personal life, focusing public attention on his professional achievements.

How long has Dr. Steven Sykes, MD been practicing Neurology?

Dr. Steven Sykes has been practicing neurology for over 20 years. He completed his medical degree and residency in neurology, followed by specialized training, and has since built a reputation as a skilled and knowledgeable neurologist with a dedication to patient care and medical research.

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Dr. Steven Sykes, MD, Podcast Epsiode Full Transcript
Ira Sternberg: Welcome to Ira's Everything Bagel, where I talk with intriguing people about everything: their passions, pursuits, and points of view. Imagine the worst headache you could have, and it’s not a migraine. It’s a lesser-known condition that affects approximately one out of a thousand people, including my wife, on either a chronic or episodic frequency. It’s called a cluster headache, and my guest today will explain its impact and possible treatment. He’s Dr. Steven Sykes, a board-certified neurologist who practices General Neurology and Clinical Neurophysiology with the Cedars-Sinai Medical Group in Santa Monica, California. For more information, go to cedars-sinai.org and cedars-sinai.org Newsroom, and you can follow Cedars on Twitter and Instagram. Dr. Sykes, Steve, welcome to the show.
Dr. Steven Sykes: Thank you for having me. It’s an important topic, and I wanted to get that little personal thing in because I’ve seen close up and personal what a cluster headache can do.
Ira: Can you explain to our listeners the distinction between cluster headaches and migraine headaches? How do the symptoms differ?
Steve: Absolutely. You made a comment in your introduction about cluster headache being potentially the worst headache that one could ever experience, and I think that’s a wise statement because the headache of cluster headache is uniquely severe. In fairness, so is the headache of migraine, and for many people, migraine will be the worst headache they will ever experience. There are many similarities between cluster headache and migraine—both can cause very severe headache. The pain of both cluster headache and migraine headache is often maximal in or around the eye. But some of the distinguishing features include how long the pain lasts. Cluster headaches tend to be shorter-lived than migraine. A typical cluster headache will last anywhere between about 15 minutes and three hours, whereas migraine headaches tend to be longer-lasting, usually somewhere between four hours and up to a few days. What I find helps to distinguish between cluster headache and migraine the best are the non-headache symptoms. Both cluster headache and migraine headache often have what we refer to as associated symptoms. For migraine, which is, as you mentioned earlier, the headache condition that people are a bit more commonly familiar with, there may be nausea, sensitivities to things like light, sound, and smells, and visual disturbances are common with migraine, like stars or sparkles in the vision. Those features are not generally expected to occur with cluster headache. Instead, cluster headache may come with some unique features that may include a drooping of the eyelid on one side, redness of the eye on the side that the pain is in, tearing on that side where the pain is, or running of the nose. Sometimes sweating in the face just on that side where the pain is will happen, and those are common or even expected features that allow us to distinguish between cluster headache and migraine. These features are sometimes referred to as autonomic features, referring to the autonomic nervous system. The autonomic nervous system is, for some reason, misbehaving in patients with cluster headache. Aside from the horrific pain that can come with it, these autonomic features are often what really helps us to identify that. Another interesting thing that distinguishes cluster headache often from migraine headache is that, even though both headache conditions can be horribly painful, patients with cluster headache often find that when they’re in the throes of an attack, they’re agitated or restless or may pace about the room. Whereas patients with migraine, who may also be experiencing intolerable pain, tend to want to curl up, lay down, pull the sheets over their head, and just be as still as possible. So, there’s this restlessness or agitation that often comes along with cluster headache.
Ira: What accounts, though, Steve, for the relative anonymity of cluster headaches in the larger world? Everybody seems to know what a migraine headache is, but you mention a cluster headache to someone, and they go, "Well, I’ve had migraine headaches; those are the worst," having no idea how bad the cluster headache is. Does somebody need to be the publicist for the cluster headache side of things? In other words, why do most people not know of cluster headaches and the impact it has on our loved ones?
Steve: I think a couple of things may account for that. One is how much less common cluster headache is than migraine headache. Cluster headache is probably something that has a prevalence of around 0.1 percent in the general population, whereas the most consistent number I’ve seen for the prevalence of migraine is somewhere around 15 percent. I think it may be even higher than that. The spectrum of experiences with migraine is quite broad, so for many people, they have had migraine at some point in their life and never recognized it. So, migraine is a much more common experience than cluster headache is, so it gets a lot more attention. I think that also the term "cluster" is used a bit loosely when people are talking about their headaches, meaning that patients will sometimes come to me and say that they think they’ve got cluster headaches, and so they have some awareness of the term. But what they’re describing are headaches that may occur day after day after day, as cluster headaches can do, but what they’re describing is some other headache issue like migraine that happens to be happening day after day after day.
Ira: I want to talk about some treatment options and possible treatment options, but before that, it seems that, based on my research, more men get cluster headaches than women. Is there a reason for that, and is it true that that’s the case?
Steve: That is true. Depending on the source that you look at, I’ve seen numbers anywhere between a ratio of six to one for men versus women with cluster headache, some saying somewhere around four to one. I haven’t found a really clear explanation for why that discrepancy exists. There are genetic factors that influence the risk of developing cluster headache, so a person with cluster headache commonly has a family member with it, and so that may have something to do with the tendency to affect the male gender a little bit more frequently. Some have argued that it has to do with recognition, and I think this ties into the difficulty estimating the prevalence of migraine. I mentioned a moment ago that some sources say 15 percent, but that it may be much higher than that. And that’s because the more recognition one has of the diagnostic criteria, the more likely there is to be recognition of the actual diagnosis, and then that would drive the actual prevalence. That’s not something that necessarily should have a gender discrepancy associated with it, but I have seen some sources cite changes in the prevalence that had some gender association with it based on increases in the recognition of the diagnostic criteria.
Ira: Do you find in your own practice that the difference between the number of male patients versus female patients reflects those general statistics, or is it a little bit different in what you do?
Steve: I haven’t tracked the population or compared the number of male patients to female patients with cluster headache. I can tell you that when I reflect on the patients that I follow in the long term with cluster headache, I do have more male patients than female patients.
Ira: Interesting. I mentioned earlier possible treatment options. In terms of treatment options or possible treatment options, are you optimistic about the options that you have, and could you describe some of the treatments that you could recommend to potential patients? Again, depending on diagnosis, they would have to go to a specialist to know that that, in fact, is what they have. But if people are listening to us and some may think they have a cluster headache situation and didn’t realize it before, is there hope for them?
Steve: Absolutely. I’m very optimistic when I am making a diagnosis of cluster headache, and that distinction is important because how we treat cluster headache typically differs from the approach we would take when treating migraine. I think it’s an interesting concept about the diagnosis and treatment of headache in general. With many conditions, the diagnostic process involves blood tests or imaging tests. In fairness, we do typically perform some type of brain imaging test in people who have cluster headache and sometimes even in patients with migraine headache. But the diagnostic testing process or brain imaging in those cases is really aimed at making sure that there isn’t some other issue that might be causing the headache. But we make these diagnoses based really on the history, and so it’s the history that distinguishes cluster headache from migraine. When we make that distinction, then we can really prioritize those treatments. With cluster headache, I think about the treatment falling into two different categories: there’s the acute treatment, or what you might think of as rescue treatment, which would be what a patient uses in the midst of an attack of pain, and then another category of treatment would be prevention treatments—things that one might do on a more regular basis in the interest of trying to prevent future attacks or to reduce the frequency of those attacks. Something that is very interesting and unique about cluster headache, again, that we don’t expect to see with other headache conditions, is that one of the common first-line acute treatments for cluster headache is oxygen. So, people with cluster headache often experience a shortening of the attack by breathing oxygen at a high flow rate. This is not oxygen that you might think of somebody with a lung disease using, where they have the nasal cannula with the prongs that go under the nose. When we’re treating cluster headache with oxygen, it’s a face mask that is delivering oxygen at a very high flow rate. Usually, we have people do that for about 15 minutes, and for reasons that I wish I could explain to you—reasons that I haven’t yet actually been able to find anything concrete in the medical literature—for many patients, not everybody, but for many patients, it can be very, very successful. The nice thing about oxygen therapy is that it’s about the safest thing we could possibly do; it’s not going to be associated with any side effects. The downside of it is that it’s cumbersome. So, it’s great when the person is at home and they can have access to an oxygen tank and the mask at home, but if the episodes are unpredictable, then it becomes less practical.
Ira: Just on a side note, one of the standout features of cluster headache happens to be that it often is predictable. Aside from the headaches often happening in what I referred to as clusters, where there may be day after day for periods of weeks of headache, they often happen at a very consistent or predictable time. So, patients may often experience headaches in the very early morning hours before they wake up from sleep. As miserable of an experience as that may be, often those patients are the best candidates for oxygen therapy as a first-line rescue treatment because the tank is right there by the bedside, so they can grab it quickly and administer the oxygen.
Steve: Ironically, the cost of oxygen compared to medication—there’s a vast difference. And yet, health plans or insurance don’t necessarily see that as a cure for the problem, or one of the cures for cluster headaches, or at least a temporary cure for cluster headaches.
Ira: You’re right. It’s a source of common frustration because some health plans will have a protocol or a series of criteria that they use in order to approve the coverage for the cost of the oxygen therapy. And those criteria that they use are all respiratory or pulmonary criteria, so their assumption automatically is that if the doctor is ordering oxygen therapy, it must be for some type of lung disease or heart disease, rather than its use being for cluster headaches. So, when presented with these forms or questionnaires from the health plan, they’ll ask questions like, "What’s the patient’s oxygen level?" and "How low does the oxygen level go?" and "What are their pulmonary function tests?" And it’s all sort of missing the mark because it’s not about any sort of lung or breathing issue.
Steve: Aside from oxygen, what are some of the other approaches to treating cluster headaches that you find effective in your practice and that you find can work in some cases, maybe not all cases, but clearly in some cases? That may be medicine, that may be—I don’t know—hypnosis or meditation or what have you.
Ira: The other acute or as-needed treatments for cluster headache are, I think of them as being borrowed from the migraine world. There’s a family of migraine medications that are referred to as triptans, the first in that family being sumatriptan, also known as Imitrex. Sumatriptan is a very common first-line treatment for people with cluster headache, an as-needed treatment for people with cluster headache. It’s an option for someone who may not respond to the high-flow oxygen therapy, or if the high-flow oxygen therapy may not be available or accessible because they’re not at home when the episode happens. One of the uniquely beneficial aspects of sumatriptan is that it can be administered by pill, which is certainly convenient, but it also has a couple of other routes of administration available. So, it can be administered by injection, and for many people, we recommend the injection of sumatriptan as first-line treatment, with the idea being that the cluster headache pain may escalate to that 10 out of 10 unbearable intensity very quickly. And by administering it by the self-administered injection, it can take effect quickly. Another option is an intranasal version, so sumatriptan comes in a nasal spray, and the medication can be absorbed very, very quickly in the nasal mucosa. There are a total of seven different triptan medications that each have their own slightly unique properties to them, so if someone had a side effect with sumatriptan or a response that was less than ideal, we may try other triptans. Another treatment that can be used—I think of this treatment as being one that spans the world of as-needed treatment and prevention treatments—is steroids. So, steroids like prednisone may not have an immediate benefit, but in somebody who’s experiencing a cluster, we may start a high dose of prednisone and use that for a period of time, a week or two weeks, with the idea being that that can break the cluster cycle or prevent the headache from happening the following day. So, when someone presents to me with a cluster headache episode, I may recommend more than one treatment or at least present the patient with different options. An oxygen tank, for example, is not something that people can always readily get the next day or the same day, whereas a prescription for sumatriptan usually can be obtained that day or the following day. Understanding that the oxygen or something like sumatriptan may be very helpful in shortening the duration of the episode, understanding that these episodes for some people end up coming back day after day after day for periods of weeks, I may be inclined to implement a course of steroids early on if the patient has that history of prolonged cluster episodes.
Ira: To the point about the prolonged cluster episodes, what is the impact that you see as a doctor on the personality of the patient?
Steve: The experience can be absolutely devastating. This is something that can have such a drastic impact on a person’s quality of life. Cluster headache is one of the few headache-related conditions that has been reported to be associated with suicide because the pain of the experience can be so incredibly severe and intolerable to the patient that that has been reported. But experiencing such severe pain on a repetitive basis, day after day after day, can have so many undesired consequences—obvious consequences on the person’s quality of life in terms of suffering from pain, but there are consequences on the person’s occupation, from the standpoint of their occupation. People may not be able to go to work if they’re having such intolerable pain. You can imagine if it’s happening day after day after day, that can really impair their productivity and their day-to-day life. But to your point about the mood, it can have very negative consequences on the mood. People with chronic pain issues—the pain can sort of spill into other aspects of their life. I mentioned earlier that cluster headaches can occur in the early morning hours, and so if somebody is awakened from sleep with a cluster headache, they may not be able to go back to sleep, and that can lead to sleep deprivation, which can have undesired effects on memory and mood.
Ira: Yes, I’ve personally experienced that with my wife, who usually gets it in the middle of the night, and that’s the worst time for it. But I’m hoping that people who listen to what you have to say may know someone or themselves who have experienced this and have themselves checked out to see whether it’s a migraine or really is a cluster—two different things. Is there a lot of research going on in the field these days for cluster headaches specifically?
Steve: There is research. I don’t know if I would say it’s a lot of research, and I think the reason for that has to do with the prevalence that we talked about earlier. Something like migraine, which affects 15 percent or more of the general population, gets a bit more attention and focus on it than something affecting 0.1 percent of the population. But there is some research happening. There’s research in trying to better understand the biology of cluster headache, which is frankly still not that well understood. There’s a lot of understanding about certain anatomical features of cluster headaches. I made reference earlier to the autonomic nervous system, and we know that’s involved. We know a structure in the brain called the hypothalamus is probably involved, and that ties into the autonomic nervous system. We know that there are some genetic factors that influence it, but why—what the crux of the biological changes that lead to this is not well understood. And I think that also ties into the fact that structurally, the brain is normal in someone with cluster headache. Doing an imaging test helps to rule out some other structural abnormality that might be causing headaches that resemble cluster headache, but in cluster headache, we expect the brain structure to be normal. I think these unanswered questions about the biology of cluster headache make the development of new therapies for it a bit more challenging. One interesting development in recent years again ties into this idea that some of the treatment approaches for cluster headache have been adopted from the migraine world. One of the injectable prevention treatments for cluster headache initially was developed as a migraine prevention treatment. So, there’s now a protocol for that monthly injection at a higher dose than what would be used for migraine headache to be used in cluster headache, and it can be a very effective prevention treatment. So, medical therapies are also being developed, I think, again, some of which have been borrowed from the migraine world, but are looking at treating patients who are not responding adequately, particularly to the prevention treatment I mentioned earlier.
Ira: What would you recommend people do if they think they have cluster headaches, or someone they love or know has cluster headaches? This will be my last question to you: From your point of view as a physician, what would you recommend people do if they think that that’s what they have based on some of what we talked about today?
Steve: Consulting with the primary care doctor or a neurologist is important. A neurologist is usually involved if cluster headache is suspected. Consulting with a neurologist is an important part of that evaluation, and really taking a very thorough history is so important because it comes back to this idea that performing a test is helpful in ruling out some alternate diagnosis, but establishing a diagnosis of cluster headache really depends upon the doctor eliciting these details about the pain. Where is it? How long does it last? And those associated symptoms I mentioned earlier, like the droopy eyelid or the red eye. Sharing the history and the experience is what is really going to help the doctor establish a diagnosis.
Ira: So, first, go see either your primary physician or a neurologist, right, and get a thorough workup so you can see what’s going on. By the way, I think it’s important to talk about what features help distinguish migraine headache from cluster headache. There’s this entity that we sometimes refer to as "cluster migraine," and so patients can have both. That’s actually not uncommon—or at least, I suppose cluster headache by definition is uncommon, or as we talked about the prevalence before, is uncommon—but in people who have cluster headache, it’s not actually that uncommon for them to experience migraine as well. The migraine may take the focus of the attention again because it is a more common occurrence or more prevalent occurrence, but recognizing those cluster features may open a window for some uniquely targeted treatments, like that oxygen is a perfect example that may not be thought of as the go-to treatment if the migraine is taking the spotlight as the potential cause.
Steve: Well, that’s a great way to leave it. My guest has been Dr. Steven Sykes, a board-certified neurologist who practices General Neurology and Clinical Neurophysiology with the Cedars-Sinai Medical Group in Santa Monica, California. For more information, go to cedars-sinai.org and cedars-sinai.org Newsroom, and you can follow Cedars on Twitter and Instagram. Dr. Sykes, Steve, thanks for being on the show.
Ira: Thank you for having me.
Steve: Join us every Thursday for a new "smear" on Ira's Everything Bagel.