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Cluster Headache FAQs (cont.)

How are cluster headaches treated?

People with cluster headaches usually receive drug therapies, although surgery and alternative treatments have helped some people.

Drug treatments of cluster headaches may be classified as symptomatic (abortive) or preventive. Abortive treatment is directed at stopping or reducing the severity of an attack, while preventive treatment is used to reduce the frequency and intensity of individual headache bouts.

Because of the short-lived nature of cluster headaches, effective preventive therapy is the cornerstone of treatment for persons who have frequent attacks that affect quality of life. Preventive therapy should begin at the start of a cluster headache cycle and continue until the person is free of headaches for at least 2 weeks. The dosage of the preventive drug may then be slowly tapered. This helps prevent a return of the headaches.

Some drugs might work well for one person but not for another. Several may have to be tried before a person finds the right one.

The short-lived and unpredictable nature of cluster headaches makes oral narcotic (opioid) analgesics far less useful for treatment than other agents. Despite this, some desperate individuals with cluster headaches take (and sometimes abuse) these substances.

Abortive treatments

Inhalation of high-flow, concentrated oxygen is extremely effective in stopping a cluster headache attack and is the treatment of choice. Although oxygen is readily available in emergency departments, its widespread use in the home setting is limited by safety concerns and other reasons.

An occipital nerve steroid injection of methylprednisolone acetate (Depo-Medrol) may stop a cluster headache attack.

The following are abortive drugs in the triptan class. They are used to stop cluster headache attacks in progress, but they have little preventive value.

Sumatriptan (Imitrex)
Naratriptan (Amerge, Naramig)
Zolmitriptan (Zomig, Zomig-ZMT)
Rizatriptan (Maxalt, Maxalt-MLT)
Almotriptan (Axert)
Frovatriptan (Frova)
Eletriptan (Relpax)

The following nontriptans are also used to stop attacks. They are sometimes effective when triptans fail.

Ergotamine (Cafatine, Cafergot, Cafetrate, Ercaf)
Dihydroergotamine (D.H.E. 45 Injection, Migranal Nasal Spray)
Acetaminophen-isometheptene-dichloralphenazone (Midrin)
Intranasal lidocaine (4%)
Intranasal capsaicin
Prednisone (Deltasone) - Too toxic for long-term use but should be tried if other therapies fail

Preventive treatments

People who have frequent cluster headache attacks and report that the attacks affect quality of life should use preventive therapy as the main element of their treatment plan. Specific headache-stopping drugs (abortive treatments) may also be taken as necessary.

The goals of preventive therapy include decreasing the frequency and severity of acute attacks and improving quality of life.

The choice of preventive medication should be tailored to the individual's profile, taking into account comorbidities (concurrent medical conditions) such as depression, weight gain issues, exercise tolerance, asthma, and pregnancy plans. All medications have side effects; therefore, selection must be individualized.

Preventive drugs include beta-blockers, tricyclic antidepressants, some anticonvulsants, calcium channel blockers, cyproheptadine (Periactin), and nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn). Unlike the specific headache-stopping drugs (abortive drugs), most of these were developed for other conditions and have been coincidentally found to have headache preventive effects. The following drugs also have preventive effects; unfortunately, they also have more side effects:

Methysergide (Sansert)
Verapamil (Calan, Verelan, Covera-HS)
Lithium carbonate (Eskalith, Lithane, Lithobid, Lithonate, Lithotabs)
Indomethacin (Indocin): This drug can cause psychosis in some people with cluster headaches.

Surgery

Some surgical operations have been successful in treating people whose cluster headaches do not respond to standard drug treatments. These procedures include nerve blocks and ablative neurosurgical procedures (operations that involve the removal or destruction of a part of the brain, the spinal cord, or a nerve). Radiosurgery (a type of surgery that uses radiant energy and does not involve cutting) has recently been used to provide a less invasive alternative for people who have persistent cluster headaches.

Alternative treatments

Some people with cluster headaches have been helped by alternative or complementary therapies such as chiropractic, acupuncture, osteopathic manipulation, and herbal remedies, though none of these treatments is supported by reliable scientific evidence.