Current Treatment Options in Neurology

, Volume 10, Issue 1, pp 30–35 | Cite as

Update on the therapy of the trigeminal autonomic cephalalgias

  • Marc E. LenaertsEmail author

Opinion statement

The treatment of trigeminal autonomic cephalalgias requires very careful attention to clinical aspects. It is important to spend enough time assessing the patient to arrive at an accurate diagnosis. Identifying trigger factors (eg, alcohol), when applicable, is part of the therapy, as behavior modifications may be necessary.

Cluster headache treatment should never be delayed; patients should be able to visit the clinic within 48 hours to expedite medication initiation. Abortive therapy typically is best achieved with nasal oxygen, sumatriptan injections, or both. Typically, a steroid taper is begun and will be continued for a few days. A prophylactic agent such as verapamil or topiramate also is initiated immediately and will be taken for a period slightly beyond the expected duration of the last cluster period before an attempt is made to taper it off. For chronic cluster headache, lithium carbonate is recommended after a few weeks if these other treatments have failed. If more than three regimens of medical therapy fail, patients should be considered for neurostimulation procedures.

Paroxysmal hemicrania most often responds to indomethacin. Failure may be due to a dosage that is too low. Gastric protection should always be given, because this medication has a high rate of gastric complications.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) remain very difficult to treat. Lamotrigine is the first recommendation.

Overall, one of the most crucial aspects of the management of patients with these disabling headache syndromes is patient education regarding what their disorder is and the reasoning behind the therapeutic options offered.


Sumatriptan Cluster Headache Zolmitriptan Chronic Cluster Headache Paroxysmal Hemicrania 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders, 2nd edition. Cephalalgia 2004, 24(Suppl 1):9–160. Available at Scholar
  2. 2.
    Lenaerts ME, Couch JR: Medication overuse headache. Minerva Med 2007, 98:221–231.PubMedGoogle Scholar
  3. 3.
    Ekbom K, Waldenlind E, Cole J, et al.: Sumatriptan in chronic cluster headache: Results of continuous treatment for eleven months. Cephalalgia 1992, 12:254–256.PubMedCrossRefGoogle Scholar
  4. 4.
    Lenaerts ME: Cluster headache and cluster variants. Curr Treat Options Neurol 2003, 5:455–466.PubMedCrossRefGoogle Scholar
  5. 5.
    Cohen AS, Matharu MS, Goadsby PJ: Electrocardiographic abnormalities in patients with cluster headache on verapamil therapy. Neurology 2007, 14:668–675.CrossRefGoogle Scholar
  6. 6.
    Schuh-Hofer S, Israel H, Neeb L, et al.: The use of gabapentin in chronic cluster headache patients refractory to first-line therapy. Eur J Neurol 2007, 14:694–696.PubMedCrossRefGoogle Scholar
  7. 7.
    The Sumatriptan Cluster Headache Study Group: Treatment for acute cluster headache with sumatriptan. N Engl J Med 1991, 325:322–326.CrossRefGoogle Scholar
  8. 8.
    van Vliet JA, Barha A, Martin V, et al.: Intranasal sumatriptan in cluster headache: randomized, placebo-controlled, double-blind study. Neurology 2003, 60:630–633.PubMedCrossRefGoogle Scholar
  9. 9.
    Cittadini E, May A, Straub A, et al.: Effectiveness of intranasal zolmitriptan in acute cluster headache: a randomized, placebo-controlled, double-blind, cross-over study. Arch Neurol 2006, 63:1537–1542.PubMedCrossRefGoogle Scholar
  10. 10.
    Couch JR, Ziegler DK: Prednisone therapy for cluster headache. Headache 1978, 18:219–221.PubMedCrossRefGoogle Scholar
  11. 11.
    Stillman M: Testosterone replacement therapy for refractory cluster headache. Headache 2006, 46:925–933.PubMedCrossRefGoogle Scholar
  12. 12.
    Matharu MS, Levy MJ, Meeran K, et al.: Subcutaneous octreotide in cluster headache: randomized placebo-controlled double-blind crossover study. Ann Neurol 2004, 56:488–494.PubMedCrossRefGoogle Scholar
  13. 13.
    Andersson PG, Jespersen LT: Dihydroergotamine nasal spray in the treatment of attacks of cluster headache. Cephalalgia 1986, 6:51–54.PubMedCrossRefGoogle Scholar
  14. 14.
    Sewell RA, Halpern JH, Pope HJ: Response of cluster headache to psilocybin and LSD. Neurology 2006, 66:1920–1922.PubMedCrossRefGoogle Scholar
  15. 15.
    Fogan L: Treatment of cluster headache. A double-blind comparison of oxygen vs. air inhalation. Arch Neurol 1985, 42:362–363.PubMedGoogle Scholar
  16. 16.
    Tfelt-Hansen P: Acute pharmacotherapy of migraine, tension-type headache and cluster headache. J Headache Pain 2007, 8:127–134.PubMedCrossRefGoogle Scholar
  17. 17.
    Nilsson Remahl AI, Ansjön R, Lind F, Waldenlind E: Hyperbaric oxygen treatment of active cluster headache: a double-blind placebo-controlled cross-over study. Cephalalgia 2002, 22:730–739.PubMedCrossRefGoogle Scholar
  18. 18.
    Goadsby PJ, Hoslin KL, Knight YE: Stimulation of the greater occipital nerve increases metabolic activity in the trigeminal nucleus caudalis and cervical dorsal horn in the cat. Pain 1997, 73:23–28.PubMedCrossRefGoogle Scholar
  19. 19.
    Goadsby PJ, Zagami AS: Stimulation of the superior sagittal sinus increases metabolic activity and blood flow in certain regions of the brainstem caudalis and upper cervical spinal cord of the cat. Brain 1991, 114:1001–1011.PubMedCrossRefGoogle Scholar
  20. 20.
    Caputi CA, Firetto V: Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache 1997, 37:174–179.PubMedCrossRefGoogle Scholar
  21. 21.
    Peres MF, Stiles MA, Siow HC, et al.: Greater occipital nerve blockade for cluster headache. Cephalalgia 2002, 22:520–522.PubMedCrossRefGoogle Scholar
  22. 22.
    Afridi SK, Shields KG, Bhola R, Goadsby PJ: Greater occipital nerve injection in primary headache syndromes—prolonged effects from a single injection. Pain 2006, 122:126–129.PubMedCrossRefGoogle Scholar
  23. 23.
    Ashkenazi A, Levin M: Greater occipital nerve block for migraine and other headaches: Is it useful? Curr Pain Headache Rep 2007, 11:231–235.PubMedCrossRefGoogle Scholar
  24. 24.
    Robbins L: Intranasal lidocaine for cluster headache. Headache 1995, 35:83-84.Google Scholar
  25. 25.
    Costa A, Pucci E, Antonaci F, et al.: The effect of cocaine and lidocaine in nitroglycerin-induced attacks in cluster headache. Cephalalgia 2000, 20:85–91.PubMedCrossRefGoogle Scholar
  26. 26.
    Burns B, Watkins L, Goadsby PJ: Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients. Lancet Neurol 2007, 369:1099–1106.CrossRefGoogle Scholar
  27. 27.
    Magis D, Allena M, Bolla M, et al.: Occipital nerve stimulation for drug-resistant chronic cluster headache: a prospective pilot study. Lancet Neurol 2007, 6:314–321.PubMedCrossRefGoogle Scholar
  28. 28.
    Schwedt TJ, Dodick DW: Occipital nerve stimulation for chronic cluster headache and hemicrania continua: pain relief and persistence of autonomic features. Cephalalgia 2006, 26:1025–1027.PubMedCrossRefGoogle Scholar
  29. 29.
    Schwedt TJ, Dodick DW, Hentz J, et al.: Occipital nerve stimulation for chronic headache—long-term safety and efficacy. Cephalalgia 2007, 27:153–157.PubMedCrossRefGoogle Scholar
  30. 30.
    Schoenen J, Di Clemente L. Vandenheede M, et al.: Hypothalamic stimulation in chronic cluster headache: a pilot study of efficacy and mode of action. Brain 2005, 128:940–945.PubMedCrossRefGoogle Scholar
  31. 31.
    Lad SP, Lipani JD, Gibbs IC, et al.: Cyber knife targeting the pterygopalatine ganglion for the treatment of chronic cluster headaches. Neurosurgery 2007, 60:E580–E581.PubMedCrossRefGoogle Scholar
  32. 32.
    Donnet A, Valade D, Regis J: Gamma knife treatment for refractory cluster headache: prospective open trial. J Neurol Neurosurg Psychiatry 2005, 76:218–221.PubMedCrossRefGoogle Scholar
  33. 33.
    Ford RG, Ford KT, Swaid S, et al.: Gamma knife treatment of refractory cluster headache. Headache 1998, 38:3–9.PubMedCrossRefGoogle Scholar
  34. 34.
    McClelland S, Barnett GH, Neyman G, Suh JH: Repeat trigeminal nerve radio surgery for refractory cluster headache fails to provide long-term pain relief. Headache 2007, 47:280–302.CrossRefGoogle Scholar
  35. 35.
    Boes CJ, Dodick DW: Refining the clinical spectrum of chronic paroxysmal hemicrania: a review of 74 patients. Headache 2002, 42:699–708.PubMedCrossRefGoogle Scholar
  36. 36.
    Cittadini E, Goadsby PJ: Revisiting the International Headache Society criteria for paroxysmal hemicrania: a series of 21 patients. Cephalalgia 2006, 26:1401–1402.Google Scholar
  37. 37.
    Antonaci F, Costa A, Ghirmai S, et al.: Parenteral indomethacin (the INDOTEST) in cluster headache. Cephalalgia 2003, 23:193–196.PubMedCrossRefGoogle Scholar
  38. 38.
    Sanahuja J, Vazquez P, Falguera M: Paroxysmal hemicrania-tic syndrome responsive to acetazolamide. Cephalalgia 2005, 25:547–549.PubMedCrossRefGoogle Scholar
  39. 39.
    Leone M, Rigamonti A, Usai S, et al.: Two new SUNCT cases responsive to lamotrigine. Cephalalgia 2000, 20:845–847.PubMedCrossRefGoogle Scholar
  40. 40.
    D’Andrea G, Granella F, Ghiotto N, Nappi G: Lamotrigine in the treatment of SUNCT syndrome. Neurology 2001, 57:1723–1725.PubMedGoogle Scholar
  41. 41.
    Gutierrez-Garcia JM: SUNCT syndrome responsive to lamotrigine. Headache 2002, 42:823–825.PubMedCrossRefGoogle Scholar
  42. 42.
    Malik K, Rizvi S, Vaillancourt PD: The SUNCT syndrome: successfully treated with lamotrigine. Pain Med 2002, 3:167–168.PubMedCrossRefGoogle Scholar
  43. 43.
    Narbone MC, Gangemi S, Abbate M: A case of SUNCT syndrome responsive to verapamil. Cephalalgia 2005, 25:476–478.PubMedCrossRefGoogle Scholar
  44. 44.
    Cohen AS, Matharu MS, Goadsby PJ: Electrocardiographic abnormalities in patients with cluster headache on verapamil therapy. Neurology 2007, 69:668–675.PubMedCrossRefGoogle Scholar
  45. 45.
    Cohen AS: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. Cephalalgia 2007, 27:824–832.PubMedCrossRefGoogle Scholar
  46. 46.
    Lenaerts M, Diederich N, Dang P: A case of SUNCT cured by the Jannetta procedure [abstract]. Cephalalgia 1997, 17:460.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Headache SectionUniversity of Oklahoma Health Sciences CenterOklahoma CityUSA

Personalised recommendations