Cluster headache is perhaps the most painful of the primary headache disorders. Its treatment includes acute, transitional, and preventive therapy. Despite the availability of many treatments, cluster headache patients can still be difficult to treat. We treated 14 cluster headache patients with greater occipital nerve block as transitional therapy (treatment initiated at the same time as preventive therapy). The mean number of headache-free days was 13.1+23.6. Four patients (28.5%) had a good response, five (35.7%) a moderate, and five (35.7%) no response. The greater occipital nerve block was well tolerated with no adverse events. Headache intensity, frequency and duration were significantly decreased comparing the week before with the week after the nerve block (P<0.003, P=0.003, P<0.005, respectively). Greater occipital nerve blockade is a therapeutic option for the transitional treatment of cluster headache. u Cluster headache, nerve block, occipital nerve

Chronic paroxysmal hemicrania (CPH) was first described by Sjaastad who also described a remitting form of this condition (1, 2). This new entity was named episodic paroxysmal hemicrania (EPH) in 1987 by Kudrow (3). It is characterized by brief, frequent attacks of unilateral orbital or temporal pain with associated autonomic symptoms. Most cases respond to indomethacin. A seasonal variant of EPH has been described (4), but never a response to treatment with cyclooxygenase (COX)-2 inhibitors. Case historyA 66-year-old woman presents with a 30-year history of headaches. She describes the pain as severe, occurring three to four times daily over the right temporal, frontal, and parietal region, and lasting 20 min There is associated nasal congestion and lacrimation of the right eye. Two years ago, her headache became seasonal, with cycles in autumn (October) and spring (March). The cycles last two to three months, after which she is pain-free until the next cycle begins. She has hypertension and her son has cluster headaches. Her physical and neurological examinations and a head computed tomography were normal. Various preventive medications, including amitriptyline, propranolol, atenolol, nifedipine, valproic acid and topiramate were of no benefit. The combination analgesic of aspirin, caffeine and butalbital brings minimal relief.Indomethacin was started at 25 mg daily and she became pain free. Routine blood work performed after indomethacin initiation revealed an elevated creatinine level. The medication was discontinued. A nephrologist was consulted and it was agreed that the COX-2 inhibitors could be tried. She was then put on valdecoxib, 10 mg twice a day for nine days with no relief. This was then changed to celecoxib, 200 mg twice a day, from which she obtained substantial but not total relief. She was then switched to rofecoxib and at 50 mg once a day, she became completely pain free. She took rofecoxib for 4 weeks and remained pain free during this time. She then had a repeat creatinine level checked which was again elevated. On advice of her nephrologist, she was taken off rofecoxib and her headaches returned almost immediately. She continued to get headaches which gradually tapered off in intensity and frequency until she went out of cycle two months later.

Cluster headaches both episodic and chronic are some of the most challenging headaches to treat. Although effective treatments are now available, some patients continue to be unresponsive to standard therapy. We present 17 patients from our practice whom we treated preventively with frovatriptan, a new triptan with a long half-life. The promising results suggest that this medication may be an useful addition to our ammaterium against this painful disorder.

Ophthalmoplegic migraine is a rare condition (1, 2). It presents with migrainous headache associated with a cranial nerve palsy, most commonly affecting the oculomotor nerve (3). We describe a case of ophthalmoplegic migraine, documenting the clinical response to treatment supported by photographic evidence.