CLUSTER HEADACHE

Unfortunately, there is no cure for cluster headache yet but there are a number of effective treatments with which it is usually possible to improve the symptoms.  They cannot be treated with over-the-counter painkillers and therefore should be treated at a specialist clinic. The treatment of cluster headache can be divided into acute and preventative treatment. Acute (abortive) treatments are used to stop a headache once it has already started. These include Oxygen and Sumatriptan injections. Oxygen therapy involves a patient inhaling a high flow of pure oxygen, through a mask, for roughly 15 minutes, at the beginning of every attack to shorten the pain. It is effective in approximately 70% of patients. Sumatriptan is given as an injection into a fatty area such as a thigh. It should be taken as soon as the pain starts and is generally effective within a few minutes with minimal side effects. The dosage is up to 12mg per day and this can be given as 2x6mg or 4x3mg injections.  Sumatriptan or Zolmitriptan Nasal Spray, while not as effective as the injection, can be used in those who do not want to self inject. Theses are limited. To 2 nasal sprays a day.  Zomig 5mg may be more effective than sumatriptan spray. People with uncontrolled blood pressure or ischaemic heart disease can not use triptans. Steroids, such as prednisone (60-100mg), can also be used as a short term treatment(7 days) and then rapidly tapered over 2-3 weeks and should not be used long term. This can abort the attack in around 70% of people allowing time for other treatments to be initiated.

Preventative (Prophylactic) treatments are used to prevent the headaches from occurring in the first place. For example, Verapamil is one of the most effective preventative agents for cluster headache but requires electrical tracing of the heart while the dose is being increased.  80-120mg three times daily can be effective but higher doses may be necessary. The effective dose should be continued. For the usual duration of the bout and then gradually tapered over a few weeks. If the attack was to recur the dose can be increased again and then reduced at 2–3 week intervals. It is  usually well tolerated although constipation (which may be severe) acid indigestion and flushing can happen and dental care is important as bleeding from gum overgrowth can occur. Other treatment include lithium carbonate or topiramate. Transitional treatments are used to obtain temporary relief while waiting for the preventive treatments to start working. This includes Greater Occipital nerve blocks. This has been found to be effective in around 50% of patients and can be used for episodic cluster or while findings other treatments. Recent studies are also looking into the potential of other drugs such as psilocybin. These are still in the research stages. The new CGRP medications may have a future use in the treatment of cluster headache. At the moment only galcanezumab has been shown to be helpful in episodic cluster headache.

Non invasive vagus nerve stimulator (GammaCore) can be used to relive pain and reduce frequency. They are held on the neck over the vagus nerve. In patients who are refractory to treatment, neurostimulation may be an option. Occipital nerve stimulation (stimulates nerves under the skin), deep brain stimulation (more invasive and targets the hypothalamus) and sphenopalatine ganglion stimulation (device in the cheek). Assessment and implantation of these devices requires specialist multidisciplinary care.

Cluster headache is a lifelong disorder in the majority of patients.  About 10% of patients with episodic cluster headache go onto develop chronic cluster headache. 

On the positive side, about one-third of patients with chronic cluster headache convert into episodic cluster headache. Despite cluster headache being a lifelong condition, it can improve in later life.