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.[1][2]
2. Triptans:
- Alternative first-line treatment is subcutaneous administration of triptan drugs, like sumatriptan and zolmitriptan.[1][3][4]
- Because of the rapid onset of an attack, the triptan drugs are usually taken by subcutaneous injection rather than by mouth.[5]
3. Lidocaine
- Lidocaine and other topical anesthetics sprayed into the nasal cavity may relieve or stop the pain,[6] 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.[7]
- Ergotamine is available as a 2 mg sublingual tablet.
- The initial dose is 2 mg and may be repeated every 30 minutes with a maximum dose of 6 mg daily and 10 mg a week.
- Intranasal Dihydroergotamine (DHE) may also be effective for cluster headache.[8][9][10]
- DHE is given as a 1 mg intravenous bolus and may be repeated at one hour, with a maximum dose of 3 mg in 24 hours.[11]
5. Other Therapies:
- Lying in a dark room may be helpful for symptoms of Horner's Syndrome.
- Cool showers
- Vigorous exercise, due to an increase in adrenaline and changes in blood pressure.
- Sexual intercourse and orgasm may terminate an attack possibly by acutely modulating hypothalamic function.[12][13][14]
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.[1]
- 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.[15][16]
References
- ↑ 1.0 1.1 1.2 May A, Leone M, Afra J, Linde M, Sándor P, Evers S, Goadsby P (2006). "EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias". Eur J Neurol. 13 (10): 1066–77. doi:10.1111/j.1468-1331.2006.01566.x. PMID 16987158. Unknown parameter
|month=ignored (help) Free Full Text (PDF) - ↑ "Vast Majority of Cluster Headache Patients Are Initially Misdiagnosed, Dutch Researchers Report". World Headache Alliance. 21/8/2003. Retrieved 2006-10-08. Check date values in:
|date=(help) - ↑ Ekbom K, Krabbe A, Micieli G, Prusinski A, Cole JA, Pilgrim AJ, Noronha D, Micelli G [corrected to Micieli G] (June 1995). "Cluster headache attacks treated for up to three months with subcutaneous sumatriptan (6 mg). Sumatriptan Cluster Headache Long-term Study Group". Cephalalgia. 15 (3): 230–6. doi:10.1046/j.1468-2982.1995.015003230.x. PMID 7553814. Vancouver style error: initials (help)
- ↑ van Vliet JA, Bahra A, Martin V, Ramadan N, Aurora SK, Mathew NT, Ferrari MD, Goadsby PJ (February 2003). "Intranasal sumatriptan in cluster headache: randomized placebo-controlled double-blind study". Neurology. 60 (4): 630–3. doi:10.1212/01.wnl.0000046589.45855.30. PMID 12601104.
- ↑ Law S, Derry S, Moore RA (July 2013). "Triptans for acute cluster headache". Cochrane Database Syst Rev (7): CD008042. doi:10.1002/14651858.CD008042.pub3. PMC 6494511. PMID 24353996.
- ↑ Mills T, Scoggin J (1997). "Intranasal lidocaine for migraine and cluster headaches". Ann Pharmacother. 31 (7–8): 914–5. PMID 9220056. Unknown parameter
|month=ignored (help) - ↑ Matharu M (February 2010). "Cluster headache". BMJ Clin Evid. 2010. PMC 2907610. PMID 21718584.
- ↑ Magnoux E, Zlotnik G (March 2004). "Outpatient intravenous dihydroergotamine for refractory cluster headache". Headache. 44 (3): 249–55. doi:10.1111/j.1526-4610.2004.04055.x. PMID 15012663.
- ↑ Mather PJ, Silberstein SD, Schulman EA, Hopkins MM (September 1991). "The treatment of cluster headache with repetitive intravenous dihydroergotamine". Headache. 31 (8): 525–32. doi:10.1111/j.1526-4610.1991.hed3108525.x. PMID 1960057.
- ↑ Nagy AJ, Gandhi S, Bhola R, Goadsby PJ (November 2011). "Intravenous dihydroergotamine for inpatient management of refractory primary headaches". Neurology. 77 (20): 1827–32. doi:10.1212/WNL.0b013e3182377dbb. PMID 22049203.
- ↑ Andersson PG, Jespersen LT (March 1986). "Dihydroergotamine nasal spray in the treatment of attacks of cluster headache. A double-blind trial versus placebo". Cephalalgia. 6 (1): 51–4. doi:10.1046/j.1468-2982.1986.0601051.x. PMID 3516408.
- ↑ Ekbom K, Lindahl J (1970). "Effect of induced rise of blood pressure on pain in cluster headache". Acta Neurol Scand. 46 (4): 585–600. PMID 4994083.
- ↑ Atkinson R (1977). "Physical fitness and headache". Headache. 17 (5): 189–91. PMID 924787. Unknown parameter
|month=ignored (help) - ↑ Gotkine M, Steiner I, Biran I. (2006). "Now dear, I have a headache! Immediate improvement of cluster headaches after sexual activity". J Neurol Neurosurg Psychiatry. 77 (11): 1296. PMID 17043304. Unknown parameter
|month=ignored (help)- Abstract - ↑ "Hallucinogenic Differential Diagnosis of Cluster headache {{subst:Ddxtable_noh}} Treatment of Neuro-Vascular Headaches". ClusterBusters. Retrieved 2006-09-22. line feed character in
|title=at position 58 (help) - ↑ Mark Honigsbaum (August 2, 2005). "Headache sufferers flout new drug law - Calls for clinical trials and rethink of legislation as patients claim that magic mushrooms can relieve excruciating condition". The Guardian. Retrieved 2006-09-22. [reprint by Multidisciplinary Association for Psychedelic Studies]