The Cleveland Clinic Manual of Headache Therapy

pp 137-150


Treatment of Trigeminal Autonomic Cephalalgias and Other Primary Headaches

  • Mark J. StillmanAffiliated withCenter for Headache and Pain, Neurological Institute, Cleveland ClinicInterdisciplinary Method for Treatment of Chronic Headache (IMATCH), Cleveland Clinic Email author 

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The treatment of the TACs and other primary headaches straddles the spectrum from simple to complex. At the simple end of the therapeutic spectrum is the use of indomethacin for the paroxysmal hemicranias, sexually related, cough, and primary stabbing headaches. More difficult to treat is hypnic headache. Paradoxically, the use of caffeine just prior to going to sleep has been beneficial for hypnic headache; lithium is the next choice. SUNCT/SUNA may respond to lamotrigine and gabapentin. Cluster headache therapy encompasses transitional or bridge therapy, abortive therapy, and preventive therapy. Steroids, in the form of bolus therapy or ipsilateral greater occipital nerve blocks, constitute the commonly used transitional therapy. A variety of acute remedies abort acute clusters, including high flow ­oxygen therapy, non-oral triptans and dihydroergotamine. For prophylaxis, escalating doses of verapamil are prescribed, with or without supplemental melatonin, lithium, topiramate and/or valproate. For the absolutely medication-resistant patient, trials are under way involving deep brain, occipital nerve, and sphenopalatine ganglion stimulation.


Cluster headache Paroxysmal hemicrania Sex headache Cough headache Primary stabbing headache Hypnic headache SUNCT SUNA