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Pharmacological Management of Cluster Headache

  • Practical Therapeutics
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Summary

Cluster headache is a distinct clinical and epidemiological entity. The International Headache Society criteria for the diagnosis of cluster headache requires at least 5 attacks of severe, unilateral, orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes. Attacks should occur at a frequency ranging from 1 every other day to 8 per day. The pain should be associated with at least 1 of the following: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis or eyelid oedema. Cluster headache can be divided into 2 clinical entities: episodic cluster headache and chronic cluster headache.

Pharmacological treatment for cluster headache can be abortive (for acute attacks), prophylactic (preventive) or a combination of both methods. In acute attacks, the fastest relief is afforded by oxygen inhalation, subcutaneous sumatriptan or dihydroergotamine mesylate. Most patients with cluster headache require prophylactic therapy. Medications with proven efficacy as prophylactic treatments include ergotamine, methysergide, corticosteroids, verapamil and lithium. Other agents that may be effective include indomethacin and valproic acid (sodium valproate).

Patients with episodic cluster headache may become resistant to a previously successful prophylactic medication. Indeed, approximately 10% of patients with cluster headaches do not respond to prophylactic pharmacotherapy or have significant contraindications to effective prophylactic agents. These patients are candidates for surgical intervention.

Patients with chronic cluster headache may require polypharmacy and eventually an ablative neurosurgical procedure. Dihydroergotamine mesylate given intravenously every 8 hours in an inpatient setting is an effective treatment for intractable cluster headache.

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  1. Temple University School of Medicine, One Penn Boulevard, Philadelphia, Pennsylvania, 19144, USA

    Stephen D. Silberstein

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Silberstein, S.D. Pharmacological Management of Cluster Headache. CNS Drugs 2, 199–207 (1994). https://doi.org/10.2165/00023210-199402030-00004

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