Cluster headache medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sabeeh Islam, MBBS[2]

Overview

Cluster headache treatment is generally divided into acute therapy or abortive therapy focused at aborting individual attacks and preventive or prophylactic therapy aimed at preventing recurrent attacks during the cluster period. Cluster headaches often go undiagnosed for many years, being confused with migraine or other causes of headache. Because of the relative rareness of the condition and ambiguity of the symptoms, some sufferers may not receive treatment in the emergency room and patients may even be mistaken as exhibiting drug-seeking behavior. Over-the-counter pain medications (such as aspirin, paracetamol, and ibuprofen) typically have no effect on the pain from a cluster headache. Unlike other headaches such as migraines and tension headaches, cluster headaches do not respond to biofeedback. Some have reported partial relief from narcotic pain killers. Percocet (Oxycodone with paracetamol) has had widespread success amongst some cluster headache patients, especially males. Anecdotal evidence indicates that cluster headaches can be so excruciating that even morphine does little to ease the pain. However, some newer medications like fentanyl (and Percocet) have shown promise in early studies and use.

Abortive Treatment

1. Oxygen:

• During the onset of a cluster headache, the most rapid abortive treatment is the inhalation of pure oxygen (12-15 liters per minute in a non-rebreathing apparatus). When used at the onset this can abort the attack in as little as 5 minutes.
• Once an attack is at its peak, oxygen therapy appears to have little effect.

2. Triptans:

• Alternative first-line treatment is subcutaneous administration of triptan drugs, like sumatriptan and zolmitriptan.
• Because of the rapid onset of an attack, the triptan drugs are usually taken by subcutaneous injection rather than by mouth.
• While available as a nasal spray, these are seldom effective to sufferers of cluster headaches due to the swelling of the nasal passages during an attack.

3. Lidocaine

• Lidocaine and other topical anesthetics sprayed into the nasal cavity may relieve or stop the pain, normally in a few minutes, but long term use is not suggested due to the side effects and possible damage to the nasal cavities.

4. Ergot compounds

• Previously, vaso-constrictors such as ergot compounds were also used, and sufferers report a similar relief by taking strong cups of coffee immediately at the onset of an attack.

5. Other Therapies:

• Sometimes, lying in a dark room will help a person if the pain is a side effect of Horner's Syndrome.
• Cool showers have helped about 15% of people who try them; while not aborting the attack, they allow the body to cool and thus help to reduce the level of pain.
• Other abortive remedies that work for some include ice, hot showers, breathing cold air, caffeine, and drinking large amounts of water in the early stages of an attack.
• Vigorous exercise has been shown in some cases to be very effective in relieving and aborting an acute attack by increasing the levels of oxygen within the body. This could also be due to an increase in adrenaline and changes in blood pressure.
• Some people report that sexual intercourse and specifically orgasm may terminate an attack possibly by acutely modulating hypothalamic function.

Prophylactic Treatment

• A wide variety of prophylactic medicines are in use, and patient response to these is highly variable.
• Current European guidelines suggest the use of the calcium channel blocker verapamil at a dose of at least 240 mg daily.
• Steroids, such as prednisolone, are also effective, with a high dose given for the first five days before tapering down.
• Methysergide, lithium and the anticonvulsant topiramate are recommended as alternative treatments.
• Muscle relaxants and atypical anti-psychotics have also been used.
• Magnesium supplements have been shown to be of some benefit in about 40% of patients.
• Melatonin has also been reported to help some.

Non-established and Research Approaches

• There is substantial anecdotal evidence that serotonergic psychedelics such as psilocybin (mushrooms) and LSD and LSA d-Lysergic acid amide(Rivea corymbosa seeds) abort cluster periods and extend remission periods.

References

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