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, therefore relaxing narrowed 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 most cluster attacks. The nasal spray form may also be effective for some patients, 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 being studied for cluster headache treatment include zolmitriptan (Zomig) in oral or nasal spray forms. Zolmitriptan may have fewer side effects than sumatriptan.

Side Effects. Side effects of sumatriptan may include:

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

Complications and Contradindications 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 an 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.

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 is also available in the form of a nasal spray, rectal suppositories, and tablets.

Ergotamine can have dangerous drug interactions with many medications, including sumatriptan. All ergotamine products approved by the Food and Drug Administration (FDA) contain a "black box" warning in the prescription label explaining these drug interactions. Because ergotamine constricts blood vessels, patients with peripheral vascular disease should not use this drug.

Local Anesthetics

Lidocaine, a local anesthetic, may be useful in nasal-spray or nasal-drop form for stopping cluster attacks. Reports suggest that it is helpful for most patients within about 40 minutes. It can have an unpleasant taste. Some doctors recommend that patients try a topical application of lidocaine to see if it helps ease pain.

Capsaicin is a compound derived from hot pepper. Some patients who have not found relief through other medications use it to treat or prevent cluster headaches by applying it intranasally. There have been few studies to confirm its effectiveness. It can cause an intense burning sensation.