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.
Cohen AS, Matharu MS, Goadsby PJ: Electrocardiographic abnormalities in patients with cluster headache on verapamil therapy. Neurology 2007, 14:668–675.CrossRefGoogle Scholar
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
The Sumatriptan Cluster Headache Study Group: Treatment for acute cluster headache with sumatriptan. N Engl J Med 1991, 325:322–326.CrossRefGoogle Scholar
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
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
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
Andersson PG, Jespersen LT: Dihydroergotamine nasal spray in the treatment of attacks of cluster headache. Cephalalgia 1986, 6:51–54.PubMedCrossRefGoogle Scholar
Sewell RA, Halpern JH, Pope HJ: Response of cluster headache to psilocybin and LSD. Neurology 2006, 66:1920–1922.PubMedCrossRefGoogle Scholar
Fogan L: Treatment of cluster headache. A double-blind comparison of oxygen vs. air inhalation. Arch Neurol 1985, 42:362–363.PubMedGoogle Scholar
Tfelt-Hansen P: Acute pharmacotherapy of migraine, tension-type headache and cluster headache. J Headache Pain 2007, 8:127–134.PubMedCrossRefGoogle Scholar
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
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
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
Caputi CA, Firetto V: Therapeutic blockade of greater occipital and supraorbital nerves in migraine patients. Headache 1997, 37:174–179.PubMedCrossRefGoogle Scholar
Peres MF, Stiles MA, Siow HC, et al.: Greater occipital nerve blockade for cluster headache. Cephalalgia 2002, 22:520–522.PubMedCrossRefGoogle Scholar
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
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
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
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
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
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
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
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
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
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