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Sumatriptan is a well-tolerated drug and is not associated with any serious side effects. It is known to be safe for patients between the ages of 18 and 65 but knowledge regarding safety and efficacy is limited outside of this age range. It is effective as a short-term as well as longer-term medication and long-term studies indicate that it does not lose efficacy over time. However, there are reports that some patients develop resistance to sumatriptan after taking it for a long period of time and it is no longer effective for them. Although sumatriptan is very effective in aborting an existing attack, it is not effective in preventing an imminent attack (prophylactic therapy).

Contraindications for sumatriptan include:

• Ischemic heart disease (e.g., angina pectoris)
• Arterial hypertension (high blood pressure)
• Past history of stroke

There are limits regarding dosages for sumatriptan administration (e.g., it is usually not recommended to be taken more than twice a day). Patients who use high doses of sumatriptan over a prolonged period of time should be monitored for electrocardiographic and other changes.

Patients who may not benefit from sumatriptan and who may need to consider alternative treatment for cluster headache include:

• Two or more headaches a day
• Contraindications or adverse effects to sumatriptan
• Chronic cluster headaches or headaches for extended periods of time
• Pregnant and nursing women

Zolmitriptan was the first oral triptan (class of drugs effective in treating severe headaches such as migraine and cluster headaches) shown to be effective in cluster headache. Its effect has since been surpassed by use of sumatriptan and oxygen. However, zolmitriptan is an alternative treatment option for patients who cannot tolerate injections, have either failed oxygen therapy, or find it too difficult to use in certain situations. It is slower-acting than sumatriptan and takes up to 30 minutes to take effect.

Corticosteroids

Corticosteroids (e.g., prednisone, dexamethasone) are the fastest acting of the abortive drugs and are also used as a transitional prophylactic medication. Most cluster patients will be headache free while taking corticosteroids. They are effective for patients with episodic cluster headache who may experience a strong reduction or elimination of headaches within 1-2 days of beginning treatment. Corticosteroids are effective for up to 70% of patients with episodic cluster headache and up to 40% of patients with chronic cluster headache.

Because of multiple side-effects that can occur with steroids, these agents are only used for short treatment courses (1 to 2 weeks or less) in patients whose headaches are very severe, intense, and frequent during an episode of cluster headache. The short-term goal of corticosteroids is to suppress headaches immediately until the longer acting preventive drugs become effective which may be up to two weeks.

Unfortunately, if corticosteroids are taken as the only drug, headaches tend to recur when the dosage is reduced below a certain level or completely eliminated. Due to adverse side effects, corticosteroids cannot be used for long-term prophylaxis of cluster headache. Side effects may include: