Treatment guidelines for cluster headache
Algorithm
Cluster HeadacheGoals of therapy
Prevent the occurrence of the headaches, while effectively and rapidly treating attacks that occur and reducing their impact on the patient’s daily activities.
First-line treatments
- Prophylaxis is the mainstay of cluster headache management, initiated at the beginning of a new cluster period. Corticosteroids are the preferred therapy for short-term relief, to ‘buy a good week’ and/or to help in the introduction of long-term prophylaxis. They are dramatically effective, but should only be used for 1 week to minimise side effects, and prednisolone 30 mg/day for 7 days is an effective first-line therapy. Methysergide and ergotamine can be used as second-line agents. Verapamil is the gold standard therapy for long-term prophylaxis.
- Acute treatments are used as rescue medication, when breakthrough attacks occur despite the use of prophylaxis. Subcutaneous sumatriptan 6 mg is the gold standard treatment.
Follow up
Therapy is required for the duration of the cluster periods, as they occur. Lithium is a suitable prophylactic agent for when verapamil fails, while nasal spray triptans or inhalation of high flow-rate (10 L/min) oxygen via a mask can be used as alternative acute medications. Diving masks can be obtained from specialist retailers, or on loan from the Migraine Action Association – www.migraine.org.uk or the Organisation for the Understanding of Cluster Headache (OUCH) – www.clusterheadaches.org.uk
When to refer
The GP who is experienced in headache management should be able to successfully manage most patients with cluster headaches. However, referral to specialist neurology or headache services may be necessary when:
- A sinister headache is suspected.
- The diagnosis does not clearly identify patients with cluster headache.
- The patient is refractory to repeated acute and/or prophylactic medications.
- The frequency of the patient’s headaches increases, despite intervention.
The GP who is not so experienced in headache management may wish to refer all their patients who have cluster headache.
Reference
Dowson AJ, Bradford S, Lipscombe S et al. Managing chronic headaches in the clinic. Int J Clin Pract 2004; in press.
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