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• Highlights
• Introduction
• Cluster Headaches
• Causes
• Prognosis
• Risk Factors
• Diagnosis
• Managing Cluster Headaches
• Treatment for Acute Attacks
• Preventive Medications
• Surgery
• Resources
• References

Headaches - cluster

Description

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

Managing Cluster Headaches

Patients with cluster headaches 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 1 - 6 years. In most of these cases, patients were inappropriately treated for other headaches (including having sinus surgery).
• Treatment for cluster headaches is problematic because most attacks come on suddenly and occur daily, while 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. Verapamil and corticosteroid drugs are most commonly used for prevention.
• 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 7 - 43% of patients responding to dummy treatments.

Treating Attacks

The most effective treatments for a cluster attack are:

• Oxygen inhalation
• Triptan drugs (injections of sumatriptan)

Relief can occur in 5 - 10 minutes.

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 treatments are available and may be used alone or in combination. In general, the steps for preventive management are:

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 drugs.

Maintenance Drugs. 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 drugs:

• Calcium-channel blockers. The calcium-channel blocker verapamil is most often used for preventing cluster headaches.
• Corticosteroids. Tapered doses of corticosteroids, such as prednisone, may be useful for preventing episodic cluster headaches.
• Lithium. Some studies suggest that lithium is the best drug for chronic cluster headaches.
• Methysergide. This drug is a serotonin inhibitor and is sometimes used for episodic cluster headaches.
• Antiseizure drugs. Of the antiseizure drugs, 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.

Other drugs that have been tried include indomethacin, melatonin, beta blockers, tricyclic and other antidepressants, and capsaicin. Combinations may be needed.

Behavioral Treatments

Lifestyle Changes. Patients should avoid the following:

• Alcohol
• Foods containing nitrates or nitrites (such as smoked meats). No other dietary factors appear to play a role, for good or ill, in this disease.
• Medications containing nitrates (such as nitroglycerin)
• Smokers who can't quit should at least stop at the first sign of an attack and not smoke throughout a cycle

One study suggested that vigorous physical exertion at the sign of an attack onset may help reduce or even abort an attack.

Surgery

Surgery may be considered for patients with chronic cluster headaches that do not respond to medications. However, surgery is also limited in its effectiveness.

Treatment for Sleep Apnea

Patients with cluster headaches who suffer from daytime sleepiness should consider being evaluated for a possible diagnosis of sleep apnea. Anyone who has both conditions should strongly consider treatment for the apnea as possible therapy for cluster headaches.

Continuous positive airway pressure (CPAP) is the standard treatment for sleep apnea. In some studies, patients with both cluster headaches and apnea who were treated with CPAP experienced substantial reduction in the frequency and severity of cluster headaches. [For more information on CPAP and sleep apnea, see In-Depth Report #65: Sleep apnea.]

• Review Date: 10/19/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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