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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.

Treatment for Acute Attacks

Oxygen Therapy

Breathing pure oxygen (by face mask, for 15 minutes or less) is one of the most effective and safest treatments for cluster headache attacks. It is often the first choice. Inhalation of oxygen raises blood oxygen levels and therefore relaxes constricted blood vessels.

Triptans

Triptans are drugs that are usually used to treat migraine headaches. They can also help stop a cluster attack. Injections of sumatriptan (Imitrex) are the standard triptan treatment. Sumatriptan injections work within 15 minutes in about three quarters of cluster attacks. The nasal spray form is also effective, and generally provides relief within 30 minutes. The spray seems to work best for attacks that last at least 45 minutes, although some people find it does not work as well as the injectable form.

Newer triptans used for cluster headache treatment include rizatriptan (Maxalt), naratriptan (Naramig, Amerge), and zolmitriptan (Zomig). A 2006 study of zolmitriptan nasal spray indicated it was effective for cluster headache relief with few side effects.

Side Effects. Many of the newer triptans may have fewer severe side effects than sumatriptan. Side effects of most triptans, however, may include:

• Nausea
• Dizziness
• Muscle weakness
• Heaviness or pressure in the chest
• Tingling and numbness in the toes
• Rapid heart rate

Complications of Triptans. The following are potentially serious problems with triptans.

• Complications on the Heart and Circulation. Triptans narrow (constrict) blood vessels. Because of this action, spasms in the blood vessels may occur, which can cause stroke and heart attack. This is a rare but very serious side effect. Patients with a history of heart attack, stroke, angina, uncontrolled high blood pressure, peripheral artery disease, or heart disease should not use triptan drugs.
• Serotonin Syndrome. Serotonin syndrome is a life-threatening condition that occurs from an excess of the brain chemical serotonin. Triptans, as well as certain types of antidepressant medications, can increase serotonin levels. These antidepressant drugs include serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) and selective serotonin/norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta) and venlafaxine (Effexor). It is very important that patients not combine a triptan drug with a SSRI or SNRI drug. Serotonin syndrome is most likely to occur when starting or increasing the dose of a triptan or antidepressant drug. Symptoms include restlessness, hallucinations, rapid heartbeat, tremors, increased body temperature, diarrhea, nausea, and vomiting. You should seek immediate medical care if you have these symptoms.

The following groups should avoid triptans or take them with caution and only under doctor supervision:

• Anyone with a history or with any risk factors for stroke, uncontrolled diabetes, high blood pressure, or heart disease.
• People taking antidepressants that increase serotonin levels.
• Pregnant women. Studies on the effects of triptans in this group are limited. One study suggested a higher incidence of preterm deliveries in pregnant women taking sumatriptan. No higher rates of still births or birth defects were reported. In general, pregnant women should avoid any medications if possible.

Ergotamine

Injections of the ergotamine-derived drug known as dihydroergotamine (DHE) can stop cluster attacks within 5 minutes in many patients, offering benefits similar to injectable sumatriptan. Ergotamine aerosols or ergotamine suppositories with caffeine may also be useful. When using the aerosol the patient usually inhales two or three times. They should be sure to shake the canister vigorously and administer the spray while making an inhalation immediately after a forced exhalation. The patient should then hold the breath for several seconds before slowly exhaling. Proper administration can produce an effective response 80% of the time. (Oral and under-the-tongue preparations of ergotamine are ineffective because of the brevity of cluster attacks.)

Local Anesthetics

Lidocaine, a local anesthetic, may be useful in nasal-spray or nasal-drop form for aborting cluster attacks. Some reports suggest that it is helpful for most patients within about 40 minutes.

• 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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