Headaches: Cluster

Description

Treatment

Breathing pure oxygen (by face mask, for 15 minutes or less) is one of the most effective and safest treatments for cluster headaches. It is often the first choice. Inhalation of oxygen raises blood oxygen levels and therefore relaxes constricted blood vessels. Between 57% to 93% of patients with episodic cluster headaches have found it to be beneficial. About half of those with chronic cluster headaches response to oxygen treatment. It should be noted that pure oxygen can be toxic to the lungs when used for long durations.

Triptans

Triptans are migraine agents that are proving to have an important role in stopping a cluster attack. Injections of sumatriptan (Imitrex) are the standard triptan treatment. Sumatriptan injections are effective within 15 minutes in about three fourths of cluster attacks. The nasal spray form is also proving to be effective, though for some people it does not work as well as the injectable form. The nasal spray is most beneficial for attacks that last at least 45 minutes. Other triptans being studies for cluster headache include rizatriptan (Maxalt), naratriptan (Naramig, Amerge), and zolmitriptan (Zomig).

Side Effects. Many of the newer triptans may have fewer severe side effects than sumatriptan. Side effects of most triptans, however, can include the following:

• Nausea.
• Dizziness.
• Muscle weakness.
• Heaviness, pain or both in the chest. (About 40% of patients taking sumatriptan experience these symptoms and they are major factors in discontinuing the drug. Newer agents may produce fewer chest symptoms.)
• Tingling and numbness in the toes.
• Rapid heart rate.
• Other effects include a warm sensation and discomfort in the ear, nose, and throat.

Complications of Triptans. The following are potentially serious problems with triptans.

• Complications on the Heart and Circulation. Triptans narrow (constrict) blood vessels. Because of this effect, very rarely spasms in the blood vessels may occur and cause serious side effects, including stroke and heart attack. Such events are not only rare but occur primarily in patients with an existing history or risk factors for these conditions.
• Serotonin Syndrome. Triptans also affect serotonin and so people taking antidepressants that increase serotonin levels (which are most antidepressants) should avoid taking both. The effects of such combinations may cause a so-called serotonin syndrome, which causes mental changes, restlessness, tremor, chills, sweating, and colitis. Some physicians believe, however, that the risk for the syndrome from taking both classes of drugs is very small.

The following groups should avoid triptans or take them with caution and only with the advisement of a physician:

• Anyone with a history or with any risk factors for stroke, uncontrolled diabetes, high blood pressure, or heart disease.
• People taking antidepressants that increase serotonin levels.
• Pregnant women. Studies on the effects of triptans in this group are limited. One study suggested a higher incidence of preterm deliveries in pregnant women taking sumatriptan. No higher rates of still births or birth defects were reported. In general, pregnant women should avoid any medications if possible.

Ergotamine

Injections of the ergotamine-derived drug known as dihydroergotamine (DHE) have stopped cluster attacks within five minutes in many patients, offering benefits similar to injectable sumatriptan. Ergotamine aerosols or ergotamine suppositories with caffeine may also be useful. When using the aerosol the patient usually inhales two or three times. They should be sure to shake the canister vigorously and administer the spray while making an inhalation immediately after a forced exhalation. The patient should then hold the breath for several seconds before slowly exhaling. Proper administration can produce an effective response 80% of the time. (Oral and under-the-tongue preparations of ergotamine are ineffective because of the brevity of cluster attacks.)

Local Anesthetics

Lidocaine, a local anesthetic, may be useful in nasal-spray or nasal-drop form for aborting cluster attacks. Some reports suggest that it is helpful for most patients within about 40 minutes.