the symptoms of cluster headache are characteristic. Early diagnosis is essential for management of this very painful condition (1)
the abrupt onset and relatively short lived nature of a cluster headache presents difficulty with management
consult expert advice (1)
there is no cure for cluster headaches at present. Objective of treatment is to (1):
shorten the cluster period in episodic cluster headache
reduce the frequency and/or severity of attacks in both episodic and chronic cluster headache
acute therapy is aimed at aborting the acute headache, and it must (2):
be fast-acting
be easily bio-available; parenteral or nasal administration is best
provide effective relief
NICE suggest (3)
acute treatment
offer oxygen and/or a subcutaneous or nasal triptan for the acute treatment of cluster headache
when using oxygen for the acute treatment of cluster headache:
use 100% oxygen at a flow rate of at least 12 litres per minute for 15 minutes with a non-rebreathing mask and a reservoir bag and
arrange provision of home and ambulatory oxygen
discuss the need for neuroimaging for people with a first bout of cluster headache with a GP with a special interest in headache or a neurologist
do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache (4).
prophylactic treatment
verapamil
is the drug of choice
starting dose - 80 mg three times a day and increasing this by 80 mg each fortnight
a daily dose of 480 mg is usually needed for adequate control (some patients may need 960 mg as day)
perform ECG – before starting treatment, 10 days after the dose change and reviewed before each dose increase
special attention should be given to the PR interval (4)
if unfamiliar with its use for cluster headache, seek specialist advice before starting verapamil, including advice on electrocardiogram monitoring
seek specialist advice for cluster headache that does not respond to verapamil
seek specialist advice if treatment for cluster headache is needed during pregnancy
Notes:
acute treatment options (1,2):
subcutaneous sumatriptan 6mg injection is the treatment of choice (maximum twice daily)
alternatives include sumatriptan 20 mg nasal spray or zolmitriptan 5 mg nasal spray, but these have delayed bio-availability
sumatriptan and zolmitriptan are contra-indicated in uncontrolled hypertension or the presence of risk factors for coronary heart disease or cerebrovascular disease. Zolmitriptan is contraindicated in patients with Wolff-Parkinson-White syndrome
oxygen via non-rebreathing masks; is safe for multiple uses and can be combined with other treatments
100% oxygen at 9-12 L/min for 15 minutes at onset of episode
other possible treatments include:
intranasal lidocaine
ergotamine (Dihydroergotamine) (4)
analgesics have no role in management of cluster headache
prevention of the attack - two approaches are generally used (1,2)
long-term (maintenance) strategy
these are taken during the entire cluster period
verapamil is first line prophylaxis (80mg tds/qds, but up to 960mg per day may be needed)
to avoid therapeutic delay, short-term prednisolone can be added to verapamil.
lithium
methysergide 1-2mg tds may be considered when other treatments fail
short-term (transitional) strategy
require expert advice
corticosteroids – eg. prednisolone 60-100mg per day for 2–5 days, then decreased by 10 mg every 2–3 days
ergotamine tartrate
greater occipital nerve injections
avoid alcohol and nicotine (1)
hypothalamic deep brain stimulation may be useful in intractable chronic cluster headache (2)
other guidance suggests a person suspected of a cluster headache requires referral to a neurologist (4)
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