Headaches: Cluster - Managing Cluster Headaches

Highlights	Risk Factors	Surgery
Introduction	Diagnosis	Resources
Cluster Headaches	Managing Cluster Headaches	References
Causes	Treatment
Prognosis	Medications

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Managing Cluster Headaches

Cluster headache patients face significant difficulties in the management and treatment of their problems:

In two surveys, patients reported a delay in the diagnosis of their headaches of between one and six years. In most of these cases, patients were inappropriately treated for other headaches (including having sinus surgery).
Treatment for cluster headaches is very problematic because most attacks come on suddenly, occur daily, and episodic cycles may continue for weeks or months. Most oral medications used for other headaches act too slowly to have much effect on a cluster headache, which typically lasts about an hour. Injected or intravenous headache medications may work but they cannot be used on a daily basis. The emphasis in managing cluster attacks, therefore, is in preventing them.
Cluster headaches are difficult to study. First, they are very uncommon, so there are few well-controlled investigations of this problem. Second, the placebo response is very high in studies on cluster headaches--with between 7% to 43% of patients responding to dummy treatments.
At this time, what evidence there is suggests that sumatriptan may be the most effective treatment. However, a 2002 report suggested that less than half of patient diagnosed cluster headaches are given this treatment. In some of these cases, insurance will not cover it.

Treating Attacks

The most effective treatments for a cluster attack are the following:

Oxygen inhalation.
Triptan drugs (injections of sumatriptan).

Relief can occur in five to 10 minutes. Of note, there is some thought that treatments which appear to relieve cluster headache symptoms may only be a delaying tactic and simply be postponing the attack.

Preventing Attacks

Because effective therapy for cluster headaches is limited, most research efforts focus on the prevention of attacks during cluster cycles. A number of agents are available and may be used alone or in combination. In general, the steps for preventive management are as follows:

Transitional Medications. Patients should use headache medications (typically a triptan, a corticosteroid, or ergotamine) to control any attacks during the transition to on-going maintenance agents.

Maintenance Agents. Prevention of attacks during a cluster cycle is extremely important. Although patients with episodic or chronic cluster headaches may be given different medications, there does not appear to be much difference in their effectiveness for either type. The following are the most commonly used preventive agents:

Calcium-channel blockers. The calcium-channel blocker verapamil is most often used for preventing cluster headaches.
Corticosteroids. Tapered doses of corticosteroids may be useful for preventing episodic cluster headaches.
Lithium. Some studies suggest that lithium is the best agent for chronic cluster headaches.
Methysergide. This agent is a serotonin inhibitor and is sometimes used for episodic cluster headaches.
Antiseizure agents. Of the antiseizure agents, valproic acid is most often used. Others that may be useful include carbamazepine, gabapentin, and topiramate.
Ergotamine. Some experts start with ergotamine, which is useful as a transitional medication.