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Headaches - cluster - Managing Cluster Headaches

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of cluster headaches.

Managing Cluster Headaches:

Management of cluster headaches focuses on:

  • Acute therapy for stopping an attack while it is happening
  • Preventive therapy for stopping or reducing attack recurrences

Treating Attacks

The most effective and best-studied treatments for a cluster attack are:

  • Oxygen inhalation
  • An injection of the triptan drug sumatriptan (Imitrex)

Relief can occur in 5 - 10 minutes. Oxygen and sumatriptan injection are sometimes given together.

Other drugs that may be used for acute attacks are nasal sprays of dihydroergotamine or lidocaine.

Preventing Attacks

Cluster headache attacks are usually short, lasting from 15 - 180 minutes, and the excruciating pain may have subsided by the time a patient reaches a doctorâ ' s office or emergency room.

Because it can be difficult to treat attacks when they occur, , treatment efforts focus on the prevention of attacks during cluster cycles. Although certain drugs are standard, preventive therapy needs to be individually tailored for each patient. The doctor may prescribe a combination of drugs.

Verapamil (Calan), a calcium-channel blocker drug, is the mainstay preventive treatment for cluster headaches. However, it can take 2 - 3 weeks for this drug to take effect. During this period, corticosteroids (typically prednisone) may be used as an initial transitional therapy. For long-term treatment of chronic cluster headaches, lithium may be used as an alternative to verapamil.

Although they are not approved for cluster headache, anti-seizure drugs such as valproate (Depakote), topiramate (Topamax), and gabapentin (Neurontin), are sometimes used for preventive treatment.

Behavioral Treatments and Lifestyle Changes

Behavioral Treatments. Behavioral therapies can be a helpful accompaniment to drug treatment. These approaches can help with pain management and enable patients to feel more in control of their condition.

Behavioral approaches include:

  • Relaxation treatment combined with biofeedback
  • Cognitive-behavioral therapy

Lifestyle Changes. Patients should avoid the following, as they may potentially trigger cluster headache attacks:

  • Alcohol. Heavy alcohol use is strongly associated with cluster headaches, although it is not clear if alcohol triggers pain or is simply used as a coping mechanism for dealing with severe pain.
  • Cigarette smoking. Many studies indicate that a majority of patients with cluster headache are cigarette smokers. While studies have not shown that quitting cigarettes will stop cluster headaches, smoking cessation should still be a goal. Smokers who can't quit should at least stop at the first sign of an attack and not smoke throughout a cycle.

Resources

References

Beck E, Sieber WJ, Trejo R. Management of cluster headaches. Am Fam Physician. 2005; 71(4): 717-24.

Burns B, Watkins L, Goadsby PJ. Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients. Lancet. 2007 Mar 31;369(9567):1099-106.

Cittadini E, May A, Straube A, Evers S, Bussone G, Goadsby PJ. Effectiveness of intranasal zolmitriptan in acute cluster headache: a randomized, placebo-controlled, double-blind crossover study. Arch Neurol. November 2006. [Epub ahead of print 11 September 2006]

Magis D, Allena M, Bolla M, De Pasqua V, Remacle JM, Schoenen J. Occipital nerve stimulation for drug-resistant chronic cluster headache: a prospective pilot study. Lancet Neurol. 2007 Apr;6(4):314-21.

May A. Cluster headache: pathogenesis, diagnosis, and management. Lancet. 2005; 366(9488): 843-55.

Rapoport AM, Mathew NT, Silberstein SD, Dodick D, Tepper SJ, Sheftell FD, Bigal ME. Zolmitriptan nasal spray in the acute treatment of cluster headache: a double-blind study. Neurology. 2007 Aug 28;69(9):821-6.

Rose KM, Wong TY, Carson AP, Couper DJ, Klein R, Sharrett AR. Migraine and retinal microvascular abnormalities: the Atherosclerosis Risk in Communities Study. Neurology. 2007 May 15;68(20):1694-700.

Schurks M, Kurth T, de Jesus J, Jonjic M, Rosskopf D, Diener HC. Cluster headache: clinical presentation, lifestyle features, and medical treatment. Headache. 2006 Sep;46(8):1246-54.

Silberstein SD, Young WB. Headache and facial pain. In: Goetz CG, eds. Textbook of Clinical Neurology. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 53.

Sostak P, Krause P, Forderreuther S, Reinisch V, Straube A. Botulinum toxin type-A therapy in cluster headache: an open study. J Headache Pain. 2007 Sep 24; [Epub ahead of print]

Van Vliet JA, Eekers PJ, Haan J, Ferrari MD; Dutch RUSSH Study Group. Evaluating the IHS criteria for cluster headache -- a comparison between patients meeting all criteria and patients failing one criterion. Cephalalgia. 2006 Mar;26(3):241-5.

  • Reviewed last on: 9/9/2008
  • Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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