Therapy goals
- Avoidance of headache attacks
- Improvement of symptoms if an attack did occur.
Therapy recommendations
- In acute cluster headache attacks, 100% oxygen should be inhaled (normobaric, 8-15 l/min; over 15 (-20) min); use of inhalation masks with reservoir bags and check valves (non-rebreather face mask); inhalation should be done in a sitting position [standard therapy/medicine of first choice; leads to freedom from pain in about 78% of patients within 15 minutes!].
- Acute cluster headache attack:
- Subcutaneous administration of sumatriptan or intranasal use of sumatriptan or zolmitriptan (serotonin receptor antagonists) (first-line agents).
- Lidocaine nasal spray (second-line agent).
- Short-term prophylaxis of cluster headache:
- Systemic glucocorticoids (first-line agents); as add-on therapy (additive) to bridge until verapamil takes effect.
- Ergotamine tartrate or triptans (second-line agents).
- The starting dose for substances for short-term prophylaxis should be chosen high enough so that the preventive effect occurs as quickly as possible (within 24 to 48 hours).
- The duration of short-term prophylaxis is limited by the substances and is usually a maximum of 2 weeks.
- Long-term prophylaxis of cluster headache:
- Verapamil (calcium antagonists) or lithium (first-line agents).
- Topiramate (antiepileptic) (second-line agent).
- In episodic cluster headache, long-term prophylaxis should be stopped completely in the remission phase.
- See also under “Further therapy“.
Further notes
- Administration of ketamine i.v. (0.5 mg/kg over 40-60 min, every 2 weeks; 1-4 applications depending on response) succeeded in stopping attacks for a period of 3 to 18 months in 100% of patients with episodic cluster headache and in 54% of patients with chronic cluster headache.Conclusion: promising result – further studies are awaited.
- Galcanezumab (CGRP antibody; dosage 300 mg, s. c., monthly), approved for migraine attack prophylaxis, reduced the number of attacks by an average of 8.7 per week (versus placebo group by 5.2) in a randomized trial in patients with episodic cluster headache. The FDA in June 2009 expanded the indication for episodic cluster headache for the drug.
- * In a randomized, placebo-controlled, parallel-group study, prophylactic treatment of cluster headache episodes using verapamil was slowly dosed up – from three times 40 mg per day on days 1-3 to finally three times daily 120 mg on days 19-30; add-on (additive) therapy is with prednisone on days 1-5 at 100 mg. As a result, the number of attacks in the first week was reduced by 25.3% compared with placebo as an add-on; 49% experienced a 50% reduction in attacks.
