Effectiveness of medication in cluster headache

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.

Practice guideline update summary: Acute treatment of migraine in children and adolescents

ObjectiveTo provide evidence-based recommendations for the acute symptomatic treatment of children and adolescents with migraine.MethodsWe performed a systematic review of the literature and rated risk of bias of included studies according to the American Academy of Neurology classification of evidence criteria. A multidisciplinary panel developed practice recommendations, integrating findings from the systematic review and following an Institute of Medicine–compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence.ResultsThere is evidence to support the efficacy of the use of ibuprofen, acetaminophen (in children and adolescents), and triptans (mainly in adolescents) for the relief of migraine pain, although confidence in the evidence varies between agents. There is high confidence that adolescents receiving oral sumatriptan/naproxen and zolmitriptan nasal spray are more likely to be headache-free at 2 hours than those receiving placebo. No acute treatments were effective for migraine-related nausea or vomiting; some triptans were effective for migraine-related phonophobia and photophobia.RecommendationsRecommendations for the treatment of acute migraine in children and adolescents focus on the importance of early treatment, choosing the route of administration best suited to the characteristics of the individual migraine attack, and providing counseling on lifestyle factors that can exacerbate migraine, including trigger avoidance and medication overuse.

Pharmacotherapy Options for the Management of Cluster Headache

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

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.