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There are two levels involved in the management of cluster headache with medication:

• Abortive treatment - relief of the acute attack
• Prophylactic (preventive or maintenance) treatment - prevention of future attacks

Abortive treatments are used to interrupt an existing headache. Prophylactic treatments can be used as transitional treatments, when strong abortive medications are given until longer acting drugs take effect, or as long term prophylactic treatments which are given for the duration of the cluster period. For most patients, medications to meet both of these goals are recommended.

Abortive Treatments

• Oxygen therapy
• Triptans
• Corticosteroids
• Ergot alkaloids
• Intranasal lidocaine
• Analgesics

Oxygen Therapy

Oxygen is an excellent abortive therapy for cluster headache and, surprisingly, many cluster patients have never been treated with oxygen therapy. Typical dosing is 100% oxygen given via a facemask at 7 to 10 liters per minute for 20 minutes while the patient is in an upright, sitting position. This therapy has been shown to be effective for pain relief in 60-80% of cluster headache patients. Most patients achieve pain relief within 10-20 minutes after starting oxygen. If there is no effect after 15-20 minutes, the oxygen therapy is discontinued.

Recently, higher flow rates of up to 15 liters per minute have shown benefit in individuals who did not respond to the lower flow rates of 7-10 liters per minute. It appears that patients under 50 with episodic cluster headache respond best to oxygen. Not all patients can use oxygen safely, especially those with a history of emphysema.

Oxygen is an attractive therapy because it is safe and easy to use. It can be given in addition to medication for acute and prophylactic treatment of cluster headache. Many cluster patients maintain two oxygen tanks, one at home and one at work. It is very important that the oxygen be administered correctly (e.g., no nasal cannula) or it will not be effective. Drawbacks to oxygen use relate to practical issues such as:

• Immediate access to oxygen all the time
• Restrictions required by fire departments in various locations

Triptans

Two types of triptan drugs are effective for treatment of cluster headache, sumatriptan and zolmitriptan.

Sumatriptan (injectable or subcutaneous) is the drug of choice since it is the most effective medication for the acute relief of an individual cluster headache. Sumatriptan belongs to a class of drugs known as selective serotonin receptor agonists and causes constriction of cranial blood vessels as well as reduced activity of the trigeminal nerve. Most patients (75-100%) will have complete relief within 15 minutes after administration. For those patients who do not experience complete relief, the severity of the headache is significantly reduced. Patients with chronic cluster headache do not respond to sumatriptan as well as those with episodic cluster headache, and the response time is slower.

The nasal spray formulation of sumatriptan is not as effective as the subcutaneous injection form though some patients report a beneficial effect within 30 minutes of administration of the nasal spray. Sumatriptan tablets taken orally have no role in cluster therapy because by the time the drug takes effect (1 to 2 hours after administration) the headache has usually subsided.