Goals of Treatment for Cluster Headaches

The goals of treatment for cluster headache include:

• Control of pain in acute attacks
• Prevention of recurrences
• Improved quality of life

Treatment options for cluster headaches include:

• Drug Therapy
• Surgery

Cluster headache patients will need medication to prevent or control headaches. If medication does not provide adequate relief, surgery may be required.

Drug Therapy

There are two levels involved in the management of cluster headache with medication:

• Abortive treatment - relief of the acute attack
• Prophylactic (preventive or maintenance) treatment - prevention of future attacks

Abortive treatments are used to interrupt an existing headache. Prophylactic treatments can be used as transitional treatments, when strong abortive medications are given until longer-acting drugs take effect, or as long term prophylactic treatments, which are given for the duration of the cluster period. For most patients, medications to meet both of these goals are recommended.

• Oxygen therapy
• Triptans
• Corticosteroids
• Ergot alkaloids
• Intranasal lidocaine
• Analgesics

Oxygen is an excellent abortive therapy for cluster headache and, surprisingly, many cluster patients have never been treated with oxygen therapy. Typical dosing is 100% oxygen given via a facemask at 7 to 15 liters per minute for 15 minutes while the patient is in an upright, sitting position. For many patients, oxygen therapy is most effective in aborting the headache if taken when pain is at maximal intensity, while in others, rather than aborting the attack, oxygen therapy may delay the attack for minutes or hours.

Oxygen therapy has been shown to be effective for pain relief in 60-80% of cluster headache patients. Most patients achieve pain relief within 10-20 minutes after starting oxygen. If there is no effect after 15-20 minutes, the oxygen therapy is discontinued. It appears that patients under 50 with episodic cluster headache respond best to oxygen. Not all patients can use oxygen safely, especially those with a history of emphysema.

Oxygen is an attractive therapy because it is safe and easy to use. It can be given in addition to medication for acute and prophylactic treatment of cluster headache. Many cluster patients maintain two oxygen tanks, one at home and one at work. It is very important that the oxygen be administered correctly (i.e., via a non-rebreather facial mask and not via nasal cannula) or it will not be effective. The non-rebreather mask delivers the highest oxygen concentration of all low-flow devices. Drawbacks to oxygen therapy relate to practical issues such as:

• Lack of immediate access to oxygen therapy equipment
• A fire code governing the use of oxygen tanks in certain locations

Two types of triptan drugs are effective for treatment of cluster headache: sumatriptan and zolmitriptan.

Sumatriptan (injectable or subcutaneous) is the drug of choice since it is the most effective medication for the acute relief of an individual cluster headache. Sumatriptan belongs to a class of drugs known as selective serotonin receptor agonists that causes constriction of cranial blood vessels as well as reduced activity of the trigeminal nerve. Most patients (75-100%) will have complete relief within 15 minutes after administration. For those patients who do not experience complete relief, the severity of the headache is significantly reduced. Patients with chronic cluster headache do not respond to sumatriptan as well as those with episodic cluster headache, and the response time is slower.