Current Treatment Options in Neurology

, Volume 1, Issue 5, pp 441–449

Cluster headache

  • Rolf Salvesen

Opinion statement

The care of patients with cluster headache has at least two goals: 1) immediately abolishing an ongoing attack and 2) stopping or shortening a bout (a cluster period). The fierceness and the relative brevity of the attacks dictate the use of a fast-acting agent. There are probably three agents fulfilling these criteria: sumatriptan (by subcutaneous injection), oxygen (inhaled through a face mask), and ergotamines (by injection or, perhaps, sublingual tablets). An abundance of data from controlled studies as well as recent clinical experience probably favors sumatriptan as the most effective alternative, the most significant drawback being its high cost. Oxygen inhalation is free of side effects and may be effective but is inconvenient to use. Ergotamines in tablet form act less rapidly, and there are more contraindications to their use. In short-term prophylaxis, however, ergotamine may still be a drug of choice if the timing of the attacks allows planned use of the drug shortly before the attack. If the timing is more irregular, steroids may at least temporaril ybreak a cycle (eg, prednisolone, 60 or 80 mg/d, gradually tapered to zero in 3 to 4 weeks). If more long-lasting prophylaxis is needed or expected, lithium carbonate ,900 mg/d, or verapamil, 360 mg/d, both have reasonable response rates. As for chronic cluster headache, lithium probably will still be the drug of choice. For a very limited group of patients with chronic cluster headache, surgery may be a last resort. The best surgical options are probably radiofrequency rhizotomy o microvascular decompression of the trigeminal nerve.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Horton BT, MacLean AR, Craig WM: A new syndrome of vascular headache: results of treatment with histamine: preliminary report. Mayo Clin Proc 1939, 14:257–260.Google Scholar
  2. 2.
    Kunkle EC, Pfeiffer JBJr, Wilhoit WM, et al.: Recurrent brief headaches in “cluster” pattern. Trans Am Neurol Assoc 1952, 77:240–243.Google Scholar
  3. 3.
    d’Allesandro R, Gamberini G, Benassi G, et al.: Cluster headache in the republic of San Marino. Cephalalgia 1986, 6:159–162.CrossRefGoogle Scholar
  4. 4.
    Ekbom K, Ahlborg B, Schele R: Prevalence of migraine and cluster headache in Swedish men of 18. Headache 1978, 18:9–19.PubMedCrossRefGoogle Scholar
  5. 5.
    Waldenlind E, Ekbom K, Torhall J: MR-angiography during spontaneous attacks of cluster headache: a case report. Headache 1993, 33:291–295.PubMedCrossRefGoogle Scholar
  6. 6.
    Dahl A, Russell D, Nyberg-Hansen R, et al.: Cluster headache: transcranial Doppler ultrasound and CBF studies. Cephalalgia 1990, 10:87–94.PubMedCrossRefGoogle Scholar
  7. 7.
    Goadsby PJ, Edvinsson L: Human in vivo evidence for trigeminovascular activation in cluster headache. Brain 1994, 117:427–434.PubMedCrossRefGoogle Scholar
  8. 8.
    Graham JR, Malvea BP, Gramm HF: Aerosol ergotamine tartrate for migraine and Horton’s syndrome. N Engl J Med 1960, 263:802–804.PubMedCrossRefGoogle Scholar
  9. 9.
    Kudrow L: Response of cluster headache attacks t oxygen inhalation. Headache 1981, 21:1–4.PubMedCrossRefGoogle Scholar
  10. 10.
    The Sumatriptan Cluster Headache Study Group: Treatment of acute cluster headache with sumatriptan. N Engl J Med 1991, 325:322–326.CrossRefGoogle Scholar
  11. 11.
    Ekbom K, Krabb A, Micelli G, et al.: Cluster headache attacks treated for up to three months with subcutaneous sumatriptan (6 mg). Cephalalgia 1995, 15:230–236.PubMedCrossRefGoogle Scholar
  12. 12.
    Gobel H, Lindner V, Pfaffenrath V, et al.: Acute therapy of episodic and chronic cluster headache with sumatriptan s.c. Results of a one-year long-term study. Nervenarzt 1998, 69:320–329. This rather large open prospective study extends the evidence for the persistent efficacy of sumatriptan and the tolerability of its long-term use.PubMedCrossRefGoogle Scholar
  13. 13.
    Ekbom KA: Ergotamine tartrate orally in Horton’s “histaminic cephalalgia.” Acta Psychiatr Scand 1947, 46(suppl):106–113.Google Scholar
  14. 14.
    Gabai IJ, Spierings ELH: Prophylactic treatment of cluster headache with verapamil. Headache 1990, 30:167–168.Google Scholar
  15. 15.
    Kudrow L: Lithium prophylaxis for chronic cluster headache. Headache 1977, 17:15–18.PubMedCrossRefGoogle Scholar
  16. 16.
    Couch JR, Ziegler DK: Prednisone therapy for cluster headache. Headache 1978, 18:219–221.PubMedCrossRefGoogle Scholar
  17. 17.
    Curran DA, Hinterberger H, Lance JW: Methysergide. Res Clin Stud Headache 1967, 1:74–122.Google Scholar
  18. 18.
    LovelyTJ, Kotsiaki X, Jannetta PJ: The surgical management of chronic cluster headache. Headache 1998, 38:590–594. A nice case series that attempts to establish microvascular decompression of the trigeminal nerve, perhaps combined with section of the nervus intermedius, as the operation of choice for chronic intractable cluster headache.PubMedCrossRefGoogle Scholar
  19. 19.
    Taha JM, Tew JM: Long-term results of radiofrequency rhizotomy in the treatment of cluster headache. Headache 1995, 35:193–196.PubMedCrossRefGoogle Scholar
  20. 20.
    Ekbom K, Monstad I, Prusinski A, et al.: Subcutaneous sumatriptan in the acute treatment of cluster headache: a dose comparison study. Acta Neurol Scand 1993, 88:63–69.PubMedCrossRefGoogle Scholar
  21. 21.
    Centonze V, Polito BM, Attolini E, et al.: Use of high sumatriptan dosages during episodic cluster headache: three clinical cases. Headache 1996, 36:389–391.PubMedCrossRefGoogle Scholar
  22. 22.
    Monstad I, Krabbe A, Micelli G, et al.: Preemptive oral treatment with sumatriptan during a cluster period. Headache 1995, 35:607–613.PubMedCrossRefGoogle Scholar
  23. 23.
    Frid A, Hardebo JE: The thigh may not be suitable as an injection site for patients self-injecting sumatriptan. Neurology 1997, 49:559–561.PubMedGoogle Scholar
  24. 24.
    Mather PJ, Silberstein SD, Schulman EA, et al.: The treatment of cluster headache with repetitive intravenous dihydroergotamine. Headache 1991, 31:525–532.PubMedCrossRefGoogle Scholar
  25. 25.
    Ekbom K: Treatment of cluster headache: clinical trials, design and results. Cephalalgia 1995, 15(suppl 15):33–36.PubMedGoogle Scholar
  26. 26.
    Sjaastad O: Cluster Headache Syndrome.Philadelphia: W.B. Saunders Co.; 1991.Google Scholar
  27. 27.
    Bussone G, Leone M, Peccarisi C, et al.: Double blind comparison of lithium and verapamil in cluster headache prophylaxis. Headache 1990, 30:411–417.PubMedCrossRefGoogle Scholar
  28. 28.
    Ekbom K: Lithium for cluster headache: review of the literature and preliminary results of long-term treatment. Headache 1981, 21:132–139.PubMedCrossRefGoogle Scholar
  29. 29.
    Manzoni GC, Bono G, Lanfranchi M: Lithium carbonate in cluster headache: assessment of its short- and long-term therapeutic efficacy. Cephalalgia 1983, 3:109–114.PubMedCrossRefGoogle Scholar
  30. 30.
    Steiner TJ, Hering R, Couturier EGM, et al.: Doubleblind placebo-controlled trial of lithium in episodic cluster headache. Cephalalgia 1997, 17:673–675. This is the first double-blind placebo-controlled study of lithium therapy for cluster headache. Perhaps because of methodologic shortcomings, this study was not able to determine definitively the place of lithium therapy in this disorder.PubMedCrossRefGoogle Scholar
  31. 31.
    Horton BT: Histamine cephalgia. Lancet 1952, 72:92–98.Google Scholar
  32. 32.
    Jammes JJ: The treatment of cluster headaches with prednisone. Dis Nerv Syst 1975, 36:375–376.PubMedGoogle Scholar
  33. 33.
    Kudrow L: Comparative results of prednisone, methysergide and lithium therapy in cluster headache In Current Concepts in Migraine Research. Edited by Greene R. New York: Raven Press; 1978:159–163.Google Scholar
  34. 34.
    Cianchetti C, Zuddas A, Marchei F: High dose intravenous methylprednisolone in cluster headache [letter]. J Neurol Neurosurg Psychiatry 1998, 64:418. This interesting case report introduces a new and perhaps better way to take advantage of steroids in the treatment of cluster headache. Use in cluster periods of longer duration may be possible without an unacceptable side-effect profile.PubMedCrossRefGoogle Scholar
  35. 35.
    Krabbe A: Limited efficacy of methysergide in cluster headache. A clinical experience. Cephalalgia 1989, 9(suppl 10):404–405.Google Scholar
  36. 36.
    Hering R, Kurutzky A: Sodium valproate in the treatment of cluster headache: an open clinical trial. Cephalalgia 1989, 9:195–198.PubMedCrossRefGoogle Scholar
  37. 37.
    Marks DR, Rapoport A, Padla D, et al.: A double-blind placebo-controlled trial of intranasal capsaicin for cluster headache. Cephalalgia 1993, 13:114–116.PubMedCrossRefGoogle Scholar
  38. 38.
    Fusco BM, Marabini S, Maggi CA, et al.: Preventative effect of repeated nasal applications of capsaicin in cluster headache. Pain 1994, 59:321–325.PubMedCrossRefGoogle Scholar
  39. 39.
    Nicolodi M, Sicuteri F, Poggion M: Hypothalamic modulation of nociception and reproduction in cluster headache. I. Therapeutic trials of leuprolide. Cephalalgia 1993, 13:253–257.PubMedCrossRefGoogle Scholar
  40. 40.
    D’Andrea G, Perini F, Granella F, et al.: Efficacy of transdermal clonidine in short-term treatment of cluster headache: a pilot study. Cephalalgia 1995, 15:430–433.PubMedCrossRefGoogle Scholar
  41. 41.
    Leone M, Attanasio A, Grazzi L, et al.: Transdermal clonidine in the prophylaxis of episodic cluster headache: an open study. Headache 1997, 37:559–560.PubMedCrossRefGoogle Scholar
  42. 42.
    Leone M, D’Amico D, Moschiano F, et al.: Melatonin versus placebo in the prophylaxis of cluster headache: a double-blind pilot study with parallel groups. Cephalalgia 1996, 16:494–496. A small but interesting and well-designed study that demonstrates a small, though significant, prophylactic effect of melatonin in cluster headache.PubMedCrossRefGoogle Scholar
  43. 43.
    Robbins L: Intranasal lidocaine for cluster headache. Headache 1995, 35:83–84.PubMedCrossRefGoogle Scholar
  44. 44.
    D’Allesandro R: Tizanidine for chronic cluster headache [letter]. Arch Neurol 1996, 53:1093.Google Scholar
  45. 45.
    Mellick GA, Mellick LB: Cluster headache management with methylphenidate (Ritalin). Headache 1998, 38:710–712. An interesting case report demonstrating the efficacy of methylphenidate in one patient.PubMedCrossRefGoogle Scholar
  46. 46.
    Sjaastad O, Salvesen R: The treatment of cluster headache. Funct Neurol 1998, 13(4):279–284.PubMedGoogle Scholar
  47. 47.
    Hassenbusch SJ, Kunkel RS, Kosmorsky GS: Trigeminal cisternal injection of glycerol for treatment of chronic intractable cluster headaches. Neurosurgery 1991, 29:504–508.PubMedCrossRefGoogle Scholar
  48. 48.
    Mathew NT, Hurt W: Percutaneous radiofrequency trigeminal gangliorhizolysis in intractable cluster headache. Headache 1988, 28:328–331.PubMedCrossRefGoogle Scholar
  49. 49.
    Sanders M, Zuurmond WW: Efficacy of sphenopalatine ganglion blockade in 66 patients suffering from cluster headache: a 12-to 70-month follow-up evaluation. J Neurosurg 1997, 87:876–880.PubMedCrossRefGoogle Scholar
  50. 50.
    Porta M, Granella F, Coppola A, et al.: Treatment of cluster headache attacks with hyperbaric oxygen. Cephalalgia 1991, 11(suppl 11):236–237.Google Scholar
  51. 51.
    DiSabato F, Fusco BM, Pelaia P, et al.: Hyperbaric oxygen therapy in cluster headache. Pain 1993, 52:243–245.CrossRefGoogle Scholar
  52. 52.
    Fogan L: Treatment of cluster headache. A double-blind comparison of oxygen vs air inhalation. Arch Neurol 1985, 42:362–363.PubMedGoogle Scholar

Copyright information

© Current Science Inc 1999

Authors and Affiliations

  • Rolf Salvesen
    • 1
  1. 1.Department of NeurologyUniversity of TromsøBodøNorway

Personalised recommendations