Pharmacotherapy Options for the Management of Cluster Headache

2013 ◽  
Vol 5 ◽  
pp. CMT.S10251 ◽  
Author(s):  
Jared L. Pomeroy ◽  
Michael J. Marmura
Keyword(s):  
Adverse Events ◽  
Cluster Headache ◽  
Preventive Treatment ◽  
Primary Headache ◽  
Good Evidence ◽  
Unilateral Headache ◽  
Acute Medication ◽  
Subcutaneous Sumatriptan ◽  
Zolmitriptan Nasal Spray ◽  
Effective Medication

Cluster headache is a primary headache syndrome characterized by attacks of severe unilateral headache typically lasting 30 to 180 minutes without treatment and prominent autonomic symptoms on the affected side. Often attacks occur in cycles lasting weeks to months with up to 8 attacks per day, and a minority of individuals continue to experience attacks throughout the year. Persons with cluster headache usually require both acute medication for attacks and preventive treatment to keep the headaches from occurring. Subcutaneous sumatriptan is the most effective medication for acute cluster attacks, but other triptans such as zolmitriptan nasal spray are also effective. inhaling 100% oxygen is also effective and is a useful treatment for those with frequent attacks or contraindications to triptans. Corticosteroids are among the most effective transitional treatments, typically used at the start of a cycle. Dihydroergotamine is an effective treatment for refractory or severe cluster headache with multiple attacks requiring large triptan doses. Verapamil and lithium are among the most effective preventive medications with good evidence of effectiveness, but other studies support the use of gabapentin, topiramate, diavalproex sodium, and methysergide, to name a few. Each of these medications requires monitoring for adverse events and can be discontinued within a few weeks of a cluster headache cycle.

Advances in Medical Management of Cluster Headache

2009 ◽  
Vol 4 (2) ◽  
pp. 95
Author(s):  
Stefan Evers ◽  
Keyword(s):  
Cluster Headache ◽  
Surgical Procedures ◽  
Acute Treatment ◽  
Maximum Dose ◽  
Controlled Trials ◽  
Scientific Evaluation ◽  
First Choice ◽  
Daily Dose ◽  
Subcutaneous Sumatriptan ◽  
Zolmitriptan Nasal Spray

Cluster headache is a rare but extremely disabling condition. For the acute treatment of cluster headache attacks, oxygen (100%) with a flow of at least 7l/minute, 6mg subcutaneous sumatriptan and 5mg zolmitriptan nasal spray are the drugs of first choice. Prophylaxis of cluster headache should be performed with verapamil in a daily dose of at least 240mg (maximum dose depends on efficacy and tolerability). Although no placebo-controlled trials are available, steroids are clearly effective in cluster headache. Methylprednisone (or equivalent corticosteroid) at least 100mg orally or up to 500mg intravenously per day over five days (then tapering down) is recommended. Methysergide, lithium and topiramate are recommended as drugs of second choice. Although in part promising, surgical procedures require further scientific evaluation before they can be recommended.

scholarly journals Update on Treatment of Cluster Headache

2021 ◽  
Vol 39 (3) ◽  
pp. 113-120
Author(s):  
Jong-Hee Sohn ◽  
Mi Ji Lee ◽  
Soo-Jin Cho
Keyword(s):  
Cluster Headache ◽  
Preventive Treatment ◽  
Primary Headache ◽  
Headache Disorder ◽  
Preventive Therapy ◽  
Systemic Steroid ◽  
Novel Treatments ◽  
Primary Headache Disorder ◽  
Cranial Autonomic Symptoms ◽  
High Flow Oxygen

Cluster headache (CH) is characterized by severe unilateral short-lasting headache attacks, accompanying ipsilateral cranial autonomic symptoms or the sense of restlessness and agitation, or both. CH is a highly disabling primary headache disorder but often not optimally treated. High-flow oxygen and parenteral triptans are the most effective treatment to treat an acute CH attack. Transitional treatments include systemic steroid therapy and sub-occipital steroid injection. For preventive therapy, verapamil and lithium are recommended as first-line treatments. Novel treatments have appeared, such as neuromodulation and medication targeting calcitonin gene-related peptide (CGRP) or its receptor. Galcanezumab, the only anti-CGRP receptor monoclonal antibody with proven efficacy for the preventive treatment of episodic CH, represents an important advance for pharmacological treatment of CH. Neuromodulation strategies, such as the non-invasive vagus nerve stimulation and the sphenopalatine ganglion stimulation, have been proven effective in reducing the intensity and frequency of attacks, and also to be safe and well tolerated.

Cluster headache

2020 ◽  
pp. 182-189
Author(s):  
Ilse F. de Coo ◽  
Leopoldine A. Wilbrink ◽  
Joost Haan
Keyword(s):  
Nervous System ◽  
Cluster Headache ◽  
Sensory System ◽  
Primary Headache ◽  
Headache Disorder ◽  
Primary Headache Disorder ◽  
Oxygen Inhalation ◽  
First Choice ◽  
Temporal Course ◽  
Subcutaneous Sumatriptan

Cluster headache is a primary headache disorder characterized by attacks of severe-to-very severe unilateral pain, located in the orbital, supraorbital, and/or temporal regions, with ipsilateral autonomic symptoms and/or restlessness. By definition, cluster headache attacks last between 15 and 180 minutes. Based on the temporal course, cluster headache can be categorized into episodic and chronic. A subdivision can also be made in primary and secondary chronic and secondary episodic. The cause of cluster headache is unknown, but probably the hypothalamus, trigeminal sensory system, some cranial blood vessels, and the autonomic nervous system are involved. A combination of acute (oxygen inhalation and/or subcutaneous sumatriptan) and prophylactic (first choice verapamil) treatment is usually necessary. For treatment-resistant patients, some experimental invasive options exist.

Sphenopalatine ganglion stimulation in cluster headache and other types of headache

Cephalalgia ◽  
2016 ◽  
Vol 36 (12) ◽  
pp. 1149-1155 ◽  
Author(s):  
Miguel JA Láinez ◽  
Ana Suller Marti
Keyword(s):  
Side Effects ◽  
Cluster Headache ◽  
Preventive Treatment ◽  
Primary Headache ◽  
Chronic Cluster Headache ◽  
Good Choice ◽  
Sphenopalatine Ganglion ◽  
Refractory Headache ◽  
Number Of Patients ◽  
One Year

Objectives The cluster headache is the most excruciatingly painful primary headache. In some patients, neither preventive treatment nor acute treatment is effective or treatment is poorly tolerated. The sphenopalatine ganglion (SPG) has an important role in the pathophysiology of cluster headache and, for this reason, SPG stimulation has been used to treat cluster headache. Methods We have reviewed the published literature on the role of the SPG in cluster headache and the use of different treatments targeting the SPG. Results Multiple procedures have been used over the SPG to treat pain and trigemino-autonomic symptoms in patients with refractory cluster headache. After obtaining good results in a small number of patients, a miniaturized stimulator was developed. Stimulation of the SPG with this device proved to be efficacious in acute and preventive treatment in a clinical trial involving patients with chronic refractory cluster headache. Implantation of the device is minimally invasive and the most frequent side-effects are mild, such as paraesthesia and pain over the maxillary area. In patients who have used the SPG device for longer than one year, the therapeutic effect remains effective and the side-effects decrease. Conclusions The reported studies have demonstrated that SPG stimulation is a safe and effective treatment for chronic cluster headache. Long-term studies have shown that the effect remains over time and this treatment could be a good choice in patients with chronic refractory headache. We need more data about its potential use in other forms of headache, such as other trigemino-autonomic headaches or migraine.

Cluster Headache: Opportunities for Pharmacists to Improve Care

2020 ◽  
pp. 089719002096429
Author(s):  
Richard Wenzel ◽  
Timothy R. Smith ◽  
Alexis S. Clark
Keyword(s):  
Cluster Headache ◽  
Primary Headache ◽  
Direct Care ◽  
Supporting Evidence ◽  
Dose Limit ◽  
Optimal Method ◽  
Associated Symptoms ◽  
Subcutaneous Sumatriptan ◽  
Negative Effect ◽  
Improve Patient

Cluster headache (CH) is a primary headache (PH) disorder characterized by recurrent attacks of severe/extremely severe unilateral pain and associated symptoms. While less prevalent than other PHs such as migraine, CH impact is substantial given the agonizing pain, negative effect on daily productivity, impaired mental health, and increased costs. Cluster headache is not optimally treated and few clinical trials are available to model therapy, especially dosing and administration. Pharmacists are well positioned to help prescribers and CH individuals with several key opportunities. Subcutaneous sumatriptan (SC SM) lower than the FDA-approved 6 mg per attack, specifically 2 mg and 3 mg, can be considered; literature describes these doses’ benefits. Moreover, lower doses may improve patient access to this treatment-of-choice. Despite the SC SM’s FDA-approved dose limit of 12 mg per 24 hours, the maximum CH dose has not been examined; this limit merits reevaluation since literature and clinical experience illustrate treatment exceeding this limit. Oxygen therapy for CH remains unfamiliar to, and under-utilized by, clinicians and CH individuals. Pharmacists can facilitate prescribing, distribution, and administration of oxygen via education. Patient education for the various CH medication devices, including oxygen, is paramount. Narcotics remain widely prescribed for CH, without supporting evidence, but with considerable abuse and diversion risks. Pharmacists are positioned to help guard against narcotic usage and to direct care toward medications endorsed by CH guidelines. Since the optimal method to initiate and discontinue drugs which may decrease CH attacks’ remains unknown, pharmacists can educate clinicians and individuals with CH to make fully informed decisions.

scholarly journals Effectiveness of medication in cluster headache

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Johannes Drescher ◽  
Andreas Khouri ◽  
Tina Katharina Amann ◽  
Charly Gaul ◽  
Peter Kropp ◽  
...  
Keyword(s):  
Cluster Headache ◽  
Citizen Science ◽  
Chronic Cluster Headache ◽  
Chi Square ◽  
Episodic Cluster Headache ◽  
Acute Medication ◽  
Zolmitriptan Nasal Spray ◽  
Effect Of Oxygen ◽  
Citizen Science Project ◽  
Better Than

Abstract Background The aim of this work is to analyze the reports on cluster headache attacks collected online in the citizen science project CLUE with respect to the effectiveness of drugs taken during the attacks. The collection of data within the framework of citizen science projects opens up the possibility of investigating the effectiveness of acute medication on the basis of a large number of individual attacks instead of a simple survey of patients. Methods Data from 8369 cluster headache attacks, containing information about acute medication taken and the assessment of its effect, were collected from 133 participants using an online platform and a smartphone app. Chi-square tests were used to investigate whether the effect of the three recommended acute drugs differs when distinguishing between participants with chronic or episodic cluster headache. Furthermore, it was investigated whether there are differences between smokers and non-smokers in the assessment of the effect of the acute medication. Results Our participants rated the effectiveness of sumatriptan 6 mg s.c. as significantly better than oxygen and zolmitriptan nasal spray. Oxygen is considered to be significantly better in episodic versus chronic cluster headache, and sumatriptan is considered to be significantly better in chronic versus episodic cluster headache. Smokers rate the effect of oxygen as significantly better than non-smokers. Conclusions Despite some methodological limitations, web-based data collection is able to support findings from clinical trials in a real world setting about effectiveness of acute cluster headache treatment in several situations.

Nocebo is the enemy, not placebo. A meta-analysis of reported side effects after placebo treatment in headaches

Cephalalgia ◽  
2011 ◽  
Vol 31 (5) ◽  
pp. 550-561 ◽  
Author(s):  
Dimos D Mitsikostas ◽  
Leonidas I Mantonakis ◽  
Nikolaos G Chalarakis
Keyword(s):  
Clinical Trials ◽  
Cluster Headache ◽  
Meta Analysis ◽  
Preventive Treatment ◽  
Primary Headache ◽  
Symptomatic Treatment ◽  
Adverse Side Effect ◽  
Primary Headaches ◽  
Nocebo Effect ◽  
Primary Headache Disorders

The aim was to determine the magnitude of the nocebo (adverse effects following placebo administration) in clinical trials for primary headache disorders. We reviewed randomized, placebo-controlled studies for migraine, tension-type headache (TTH), and cluster headache treatments published between 1998 and 2009. The frequency of nocebo was estimated by the percentage of placebo-treated patients reporting at least one adverse side effect. The dropout frequency was estimated by the percentage of placebo-treated patients who discontinued the treatment due to intolerance. In studies of symptomatic treatment for migraine, the nocebo and dropout frequencies were 18.45% and 0.33%, but rose to 42.78% and 4.75% in preventative treatment studies. In trials for prevention of TTH, nocebo and dropout frequencies were 23.99% and 5.44%. For symptomatic treatment of cluster headache, the nocebo frequency was 18.67%. Nocebo is prevalent in clinical trials for primary headaches, particularly in preventive treatment studies. Dropouts due to nocebo effect may confound the interpretation of many clinical trials.

scholarly journals Primary headache disorders

2019 ◽  
Vol 9 (3) ◽  
pp. 233-240 ◽  
Author(s):  
Peter J. Goadsby
Keyword(s):  
Cluster Headache ◽  
Nerve Stimulation ◽  
Controlled Trial ◽  
Preventive Treatment ◽  
Primary Headache ◽  
Migraine Treatment ◽  
Headache Disorders ◽  
Primary Headache Disorders ◽  
Trigeminal Nerve Stimulation ◽  
Episodic Cluster Headache

Purpose of reviewTo review 5 new areas in primary headache disorders, especially migraine and cluster headache.Recent findingsCalcitonin gene-related peptide (CGRP) receptor antagonists (gepants—rimegepant and ubrogepant) and serotonin 5-HT1F receptor agonists (ditans—lasmiditan) have completed phase 3 clinical trials and will soon offer novel, effective, well-tolerated nonvasoconstrictor options to treat acute migraine. CGRP preventive treatment is being revolutionized after the licensing of 3 monoclonal antibodies (MABs), erenumab, fremanezumab, and galcanezumab, with eptinezumab to follow, especially designed for migraine; they are effective and well tolerated. For patients seeking a nondrug therapy, neuromodulation approaches, single-pulse transcranial magnetic stimulation, noninvasive vagus nerve stimulation (nVNS), and external trigeminal nerve stimulation, represent licensed, well-tolerated approaches to migraine treatment. For the acute treatment of episodic cluster headache, nVNS is effective, well tolerated, and licensed; nVNS is effective and well tolerated in preventive treatment of cluster headache. The CGRP MAB galcanezumab was effective and well tolerated in a placebo-controlled trial in the preventive treatment of episodic cluster headache. Sphenopalatine ganglion stimulation has been shown to be effective and well tolerated in 2 randomized sham-controlled studies on chronic cluster headache. Understanding the premonitory (prodromal) phase of migraine during which patients experience symptoms such as yawning, tiredness, cognitive dysfunction, and food cravings may help explain apparent migraine triggers in some patients, thus offering better self-management.SummaryHeadache medicine has made remarkable strides, particularly in understanding migraine and cluster headache in the past 5 years. For the most common reason to visit a neurologist, therapeutic advances offer patients reduced disability and neurologists a rewarding, key role in improving the lives of those with migraine and cluster headache.

scholarly journals Osmophobia in primary headache patients: associated symptoms and response to preventive treatments

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Marianna Delussi ◽  
Anna Laporta ◽  
Ilaria Fraccalvieri ◽  
Marina de Tommaso
Keyword(s):  
Cluster Headache ◽  
Rating Scale ◽  
Preventive Treatment ◽  
Primary Headache ◽  
Tension Type Headache ◽  
Primary Headaches ◽  
Self Rating ◽  
Type Headache ◽  
Headache Center ◽  
Headache Patients

Abstract Background Osmophobia, is common among primary headaches, with prevalence of migraine. The study aimed to evaluate prevalence and clinical characteristics of patients with osmophobia in a cohort of primary headache patients selected at a tertiary headache center. The second aim was to verify the possible predicting role of osmophobia in preventive treatment response in a sub cohort of migraine patients. Methods This was an observational retrospective cohort study based on data collected in a tertiary headache center. We selected patients aged 18–65 years, diagnosed as migraine without aura (MO), migraine with aura (MA) or Chronic Migraine (CM), Tension-Type Headache (TTH); and Cluster Headache (CH). We also selected a sub-cohort of migraine patients who were prescribed preventive treatment, according to Italian Guidelines, visited after 3 months follow up. Patients were considered osmophobic, if reported this symptom in at least the 20% of headache episodes. Other considered variables were: headache frequeny, the migraine disability assessment (MIDAS), Allodynia Symptom Checklist, Self-rating Depression scale, Self-rating Anxiety scale, Pain intensity evaluated by Numerical Rating Scale-NRS- form 0 to 10. Results The 37,9% of patients reported osmophobia (444 patients with osmophobia, 726 without osmophobia). Osmophobia prevailed in patients with the different migraine subtypes, and was absent in patients with episodic tension type headache and cluster headache (chi square 68.7 DF 7 p < 0.0001). Headache patients with osmophobia, presented with longer hedache duration (F 4.91 p 0.027; more severe anxiety (F 7.56 0.007), depression (F 5.3 p 0.019), allodynia (F 6 p 0.014), headache intensity (F 8.67 p 0.003). Tension type headache patients with osmophobia (n° 21), presented with more frequent headache and anxiety. A total of 711 migraine patients was visited after 3 months treatment. The change of main migraine features was similar between patients with and without osmophobia. Conclusions While the present study confirmed prevalence of osmophobia in migraine patients, it also indicated its presence among chronic tension type headache cases, marking those with chronic headache and anxiety. Osmophobia was associated to symptoms of central sensitization, as allodynia. It was not relevant to predict migraine evolution after first line preventive approach.

Migraine and Cluster Headache-Their Management with Sumatriptan: A Critical Review of The Current Clinical Experience

Cephalalgia ◽  
1995 ◽  
Vol 15 (5) ◽  
pp. 337-357 ◽  
Author(s):  
M Wilkinson ◽  
V Pfaffenrath ◽  
J Schoenen ◽  
H-C Diener ◽  
TJ Steiner
Keyword(s):  
Adverse Events ◽  
Cluster Headache ◽  
Study Data ◽  
Uncontrolled Hypertension ◽  
Recommended Dosage ◽  
Trigeminovascular System ◽  
Double Blind ◽  
Migraine Headaches ◽  
Subcutaneous Sumatriptan ◽  
Post Marketing

Sumatriptan is a potent and selective agonist at the vascular 5HT1 receptor which mediates constriction of certain large cranial blood vessels and/or inhibits the release of vasoactive neuropeptides from perivascular trigeminal axons in the dura mater following activation of the trigeminovascular system. The mode of action of this drug in migraine and cluster headache is discussed. On the basis of a detailed review of all published trials and available data from post-marketing studies, the efficacy, safety, tolerability and the place of oral and subcutaneous sumatriptan in the treatment of both conditions are assessed. A number of double-blind clinical trials have demonstrated that sumatriptan 100 mg administered orally is clearly superior to placebo in the acute treatment of migraine headache and achieves significantly greater response rates than ergotamine or aspirin. In other studies, 70 to 80% of patients receiving sumatriptan 6 mg sc experienced relief of migraine headaches by 1 or 2 h after administration, and patients consistently required less rescue medication for unresolved symptoms. Sumatriptan was also effective in relieving associated migraine symptoms like nausea and vomiting. Sumatriptan was equally effective regardless of migraine type or duration of migraine symptoms. Overall, approximately 40% of patients who initially responded to oral or subcutaneous sumatriptan experienced recurrence of their headache usually within 24 h, effectively treated by a further dose of this drug. In 75% of patients with cluster headache treated with sumatriptan 6 mg sc, relief was achieved within 15 min. Based on pooled study data, sumatriptan is generally well tolerated and most adverse events are transient. Adverse events following oral administration include nausea, vomiting, malaise, fatigue and dizziness. With the subcutaneous injection, injection site reactions occur in approximately 30%. Chest symptoms are reported in 3 to 5% but have been associated with myocardial ischaemia only in rare isolated cases. The recommended dosage of sumatriptan at the onset of migraine symptoms is 100 mg orally or 6 mg subcutaneously. The recommended dosage for cluster headache is 6 mg sumatriptan sc. Sumatriptan must not be given together with vascoconstrictive substances, e.g. ergotamines, or with migraine prophylactics with similar properties, e.g. methysergide. Sumatriptan should not be given during the migraine aura. It is contraindicated in patients with ischaemic heart disease, previous myocardial infarction, Prinzmetal (variant) angina and uncontrolled hypertension.

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