Pharmacotherapy for Cluster Headache

Abstract

Cluster headache is characterised by attacks of excruciating unilateral headache or facial pain lasting 15 min to 3 h and is seen as one of the most intense forms of pain. Cluster headache attacks are accompanied by ipsilateral autonomic symptoms such as ptosis, miosis, redness or flushing of the face, nasal congestion, rhinorrhoea, peri-orbital swelling and/or restlessness or agitation. Cluster headache treatment entails fast-acting abortive treatment, transitional treatment and preventive treatment. The primary goal of prophylactic and transitional treatment is to achieve attack freedom, although this is not always possible. Subcutaneous sumatriptan and high-flow oxygen are the most proven abortive treatments for cluster headache attacks, but other treatment options such as intranasal triptans may be effective. Verapamil and lithium are the preventive drugs of first choice and the most widely used in first-line preventive treatment. Given its possible cardiac side effects, electrocardiogram (ECG) is recommended before treating with verapamil. Liver and kidney functioning should be evaluated before and during treatment with lithium. If verapamil and lithium are ineffective, contraindicated or discontinued because of side effects, the second choice is topiramate. If all these drugs fail, other options with lower levels of evidence are available (e.g. melatonin, clomiphene, dihydroergotamine, pizotifen). However, since the evidence level is low, we also recommend considering one of several neuromodulatory options in patients with refractory chronic cluster headache. A new addition to the preventive treatment options in episodic cluster headache is galcanezumab, although the long-term effects remain unknown. Since effective preventive treatment can take several weeks to titrate, transitional treatment can be of great importance in the treatment of cluster headache. At present, greater occipital nerve injection is the most proven transitional treatment. Other options are high-dose prednisone or frovatriptan.

Phase Specific Pain Localization in Cluster Headache Patients.

“…Results from previous international cross-sectional surveys on CH describe demography (2,5,6), clinical characteristics including symptoms (2,4,6,7), and diagnostic and therapeutic challenges (8)(9)(10). Current pharmaceutical management of CH(11) − (12) including preventive treatment involves substances like triptans, prednisolone, lithium, verapamil and others which, especially when used by patients in high doses over long periods of time, have the potential for side effects like cardiac events (13), fatigue, nausea, tremor, depression, increased serum glucose and others (12).…”

“…The top 10 frequencies for ventral points are: 12,18,19,11,25,17,10,24,5,20. The top 10 frequencies for dorsal points are: 34, 40, 35, 39, 33, 32, 42, 44 ,38, 43.…”

“…Pain location frequency is mainly congruent with onset (in and around the eye), except for dorsal points. Signi cant differences compared to radiation are reported for: (peri) orbital (5,11,12,18,19), frontal (10) and temporal (25) pain locations. (Fig.…”

“…The top 10 ventral points are: 21,26,24,29,25,30,12,11,19,18. The top 10 dorsal points are: 35, 40, 36, 44, 34, 43, 39, 42, 38, 37.…”

Erenumab for chronic cluster headache: A case report

“…2,3 Lithium has limited evidence for efficacy in cluster headache and may cause tremor, while long-term use can provoke kidney dysfunction and hypothyroidism. 4 Since calcitonin gene-related peptide (CGRP) is believed to be involved in the pathophysiological development of cluster headache 5 and monoclonal antibodies against CGRP or the CGRP-receptor are effective in preventing migraine with few side effects, several trials investigating CGRP antagonists for the preventive treatment of cluster headache have been conducted. Galcanezumab (300 mg) has been shown to significantly reduce the occurrence of cluster headache attacks during the first 3 weeks in patients being treated for episodic cluster headache.…”