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11 Articles in Volume 10, Issue #6
Assessing Pain of the Pediatric Patient in the Emergency Setting
Testosterone Replacement in Chronic Pain Patients
Why Some Patients Require High Dose Opioid Therapy
Raising Pain Tolerance Using Guided Imagery
Long-Standing Groin Pain in a Male Athlete
FDA’s Proposed Risk Evaluation and Mitigation Strategy (REMS) for Opioids
Platelet Rich Plasma Prolotherapy as First-line Treatment for Meniscal Pathology
Cluster Headache
Effectiveness of Laser and Non-Coherent Light Therapies
Opinion on Preliminary Guidelines for the Clinical Diagnostic Criteria for Fibromyalgia
Doctors May Now Electronically Prescribe Schedule II Drugs

Cluster Headache

Summary of cluster headache characteristics and update on abortive treatments utilizing first-line and second-line medications.

Editor’s note: this article is updated and adapted from Management of Headache and Headache Medications, 2nd Edition by Lawrence Robbins, MD (Springer Verlag. New York. 2000. pp 139-145) and focuses on abortive medications. A subsequent article will discuss preventive medications for cluster headache.

Robert Foery, PhD, DABCC/TC

Cluster headache is among the most severe pains known to mankind. It is characterized by excruciating, debilitating pain lasting from 15 to 180 minutes, or occasionally longer. The pain is usually located around or through one eye or on the temple. The series of cluster headaches usually lasts several weeks to several months, once or twice per year. Clusters may occur every other year, or even less frequently. Several of the following are usually present: lacrimation, nasal congestion, rhinorrhea, conjunctival injection, ptosis, miosis of the pupil, or forehead and facial sweating. Nausea, bradycardia and general perspiration also occur in many patients. Attacks usually recur on the same side of the head. Cluster headaches tend to occur more in spring and fall. There is usually no family history of cluster headache, but occasionally there is such a family history.

Specific Characteristics of Cluster Headaches

Males are afflicted more than females by a 2.5 to 1 ratio. The onset of the clusters is usually between the age of 20 and 45, but there are many cases of clusters in teenagers and occasionally clusters begin in the 50s or 60s and rarely in the 70s. Women tend to have an older age of onset for their cluster headaches than men. Occasionally a brief aura may occur. The prevalence is 0.4% of the population. See Table 1 for a summary of characteristics.

Table 1. Typical Characteristics of Patients with Cluster Headaches
  • Begins between ages 20 and 45, approximately 0.4% of the population
  • Male predominance in a 2.5 to 1 ratio
  • Same time of year with no headache in between the cluster cycles
  • Primarily nocturnal attacks (but may be anytime)
  • During cluster cycle, alcohol triggers the headaches
  • Severe, excruciating, unilateral pain—usually periorbital
  • Ipsilateral rhinorrhea, lacrimation, conjunctival hyperemia, sweating of the forehead, Homer’s syndrome

The pain of the cluster attack is extreme and starts very quickly, usually without an aura or a warning. Within minutes, it becomes very severe. Although the pain is usually located about the eye or temple, it may be more intense in the neck or facial areas. Although usually unilateral, the pain changes sides in 10% to 15% of patients—either during a cluster cycle or the next cycle may see pain on the opposite side. The pain itself is excruciating, described in various manners as sharp, stabbing—“like my eye is being pulled out” and occasionally, throbbing.

The length of attack varies, but 45 minutes is the average. Cluster patients usually experience one or two headaches per day, but this may increase to as many as seven per 24 hours or decrease to as little as one or two per week. They usually occur around the same time each day, with the time period 9 pm to 10 am being the most frequent. Approximately half of the patients awaken from sleep with the headaches.

Cluster cycles, except in the chronic variety, usually last 3 to 8 weeks and then stop until the next bout of clusters. The clusters occasionally last as little as several days, or as long as 5 months at which time we begin to think that they may have converted to the chronic cluster type. Ten percent of cluster patients have chronic clusters in which there is no break of at least six months between attacks. One or two bouts of the clusters per year is average for most patients. They may increase in frequency with only several months in between bouts or several years may elapse between attacks. When periodic clusters begin at older ages, the chance of conversion to chronic cluster becomes greater. The natural history of clusters is not known, but the tendency is for the cluster series to stop at a certain age. Many patients “lose” their clusters in the late 30s or 40s, particularly if they have had them for many years.

During the cluster series, over half of the patients are very sensitive to alcohol and most patients will have an attack triggered by ingestion of alcohol. The other ‘headache foods’ are less important, but avoiding MSG, aged cheeses and meats, and chocolate is prudent during the cluster series. MSG, in particular, seems to trigger a more sever cluster in some patients. Cluster patients may have their clusters after stress is over and occasionally excessive cold, heat, or bright light have been associated with the precipitation of a cluster. However, most cluster patients have very little control over the clusters, except with medication.

The typical episodic cluster series builds over one to two weeks and peaks for one to three weeks and then decreases. In the 10% of cluster patients with chronic clusters, periods of peaks and valleys with the headaches also occur but an extended break without any clusters is not present. Chronic clusters are not usually consistent throughout the year but tend to increase in certain seasons. In managing the clusters, we keep in mind the fact that the clusters build and then peak so that I often treat them with somewhat less medication—particularly corticosteroids—in the beginning of a cluster period. The natural history of clusters is unknown. However, it appears as if the more years a patient has them, the more likely they are to abate.

Non-Medication Treatment of Cluster Headache

Other than medication, very little is available for sufferers of cluster headache. The pain is too severe for relaxation methods and some patients state that biofeedback or relaxation may actually precipitate or increase a cluster. However, learning simple deep breathing techniques or relaxation methods does aid some patients in helping to curb the anticipation of the cluster attacks. Much anxiety is generated during the day when the patient knows that nighttime brings intense, excruciating pain.

Icing the area of pain may help, although sometimes heat will be more effective. Some patients let the shower run hot water on their cervical area, or they use a shower water massage apparatus to allow the hot water to run over their cervical or frontal area. Pressing over the temporal area with moderate pressure is occasionally helpful. Cluster patients usually feel better when moving about during an attack. They tend to be active (such as pacing) as opposed to the quiet sought by migraineurs.

Medications For Cluster Headache

For most patients, both abortive and preventive medications are helpful and only in a minority of situations do we simply use abortive medicines. This article will focus only on the abortive medications.

The abortive treatment for clusters is the same for episodic and for chronic cluster headaches. Since the headache is very intense from the beginning and the pain is severe and excruciating, medication to aid the attack must act quickly. Most cluster attacks last less than one hour, averaging about 45 minutes, and thus oral pain medication is only of limited value. However, in patients whose attacks do last for more than one hour, pain medications may be useful—particularly if the standard cluster abortives are not completely effective. Anti-emetics are also used for those patients with nausea, and the sedative effect of these is often helpful.

First-Line Cluster Abortive Medications

The first line abortive cluster medications are as follows:

  1. Inhaled oxygen
  2. Sumatriptan injections
  3. Imitrex® (sumatriptan) or Zomig® (zolmitriptan) nasal spray

Oxygen. Oxygen is effective in approximately 70% of cluster headache patients. To obtain a small tank with a mask is relatively easy and not terribly expensive. The tanks are usually rented for one month. If feasible, most patients with cluster headaches should attempt to use oxygen for their attacks. The patient should be sitting with the body leaning slightly forward. A mask is used and 100% oxygen is inhaled at 12 liters per minute. In healthy patients with no pulmonary problems, the oxygen may be inhaled for 15 to 20 minutes.

Sumatriptan Injections. Injectable sumatriptan (Imitrex®, Sumavel™, or generic) is generally effective. Suma-triptan pills are more helpful for migraine than for cluster headache, but oral triptans are occasionally adequate. Many patients are reluctant to give themselves injections but, for those who are willing, injected sumatriptan is usually effective—often within minutes—and with a minimum of side effects. Oxygen may be used in conjunction with sumatriptan, and escape pain medication may also be utilized.

The dosage of sumatriptan is usually 4 to 6mg given subcutaneously at the onset of the cluster headache. A repeat dose may be given at least one hour after the first injection. Two injections, or 12mg, is the maximum recommended dosage per 24 hours. Sumatriptan is administered subcutaneously by the use of a convenient auto-injector device. Sumavel™ DosePro™ is a ‘needle-free’ sumatriptan injection. Also, vials of sumatriptan are available for use with an insulin syringe.

Daily use of sumatriptan has not been studied extensively. Thus, until further studies are known, prudent use of suma-triptan would dictate that no more than six injections per week be taken for cluster headache (less for migraineurs).

The side effects of sumatriptan are generally less than dihydroergotamine (DHE). Transient pain at the site of injection is common, and ‘icing’ the injection site prior to use may decrease this burning pain. Other side effects include tingling sensations, disturbances of taste, heat flashers, and feelings of pressure or heaviness. Side effects tend to be short lasting. Chest symptoms, flushing, dizziness, and overall weakness may also occur. Minor transient increases in blood pressure have been seen. Nausea is relatively common. Sumatriptan should not be used in children, in pregnant women, in the presence of hepatic or renal impairment, or with cardiovascular disease. Patients over the age of 45 should be screened for cardiac risk factors. The frequent chest pressure that occurs is not usually felt to be of cardiac origin.

Sumatriptan or Zolmitriptan Nasal Spray. While not as effective as the injection for cluster headache, the nasal spray is very convenient and many patients prefer this route of administration. We usually limit the sprays to two per day, but for cluster headaches we will occasionally utilize a third spray as well. Of the two nasal sprays, Zomig nasal spray 5mg is more effective than the sumatriptan spray. While not as rapidly effective as the injections, the nasal spray works faster than triptan tablets. Speed is essential in relieving cluster headache yet occasionally patients prefer the oral triptans.

Second-Line Cluster Abortive Medications

Second line therapies include oral triptans, ergots and dihydroergotamine (DHE), oral pain medications and intranasal lidocaine.

Oral Triptans. Any of the oral triptans may help, but are usually too slow for cluster headache. Sumatriptan 100mg is the most commonly used oral triptan.

Ergotamine Tartrate. Strong vasoconstrictors, the ergotamines have many limitations. Ease of administration (they are available as tablets) is a major advantage of the ergots. The frequent side effects of nausea and nervousness limit their use. In older patients, the risk of angina or an actual myocardial infarction restricts its use. The rebound headaches that occur in migraineurs do not seem to be as prevalent a problem in cluster headache patients. The primary ergotamine preparations are generic Cafergot® pills, suppositories and Ergomar® sublingual pills. Peripheral vascular disease or hypertension are contraindications. Er-gotamines may exacerbate peptic ulcer disease. The effective dose of ergotamine varies widely among patients. Ergots may be combined with the use of oxygen and other abortive measures but not with triptans.

Ergomar. Tablets contain 2mg of ergotamine tartrate with no caffeine. The usual dose is one pill sublingually at the onset of the cluster attack. Ergomar may also be swallowed and this route may be just as effective as the sublingual method. This may be repeated once in one or more hours and limited to two pills per 24 hours. Nausea is a common side effect as is a bitter or “bad’ taste in the mouth. Nervousness is a frequent side effect, but less so than with Cafergot because there is no caffeine in Ergomar. Ergotamines need to be used with great caution in the presence of hypertension, peripheral vascular disease, or peptic ulcer disease. If chest symptoms occur, ergots should be discontinued.

Generic Cafergot (only generic available). Consists of 1mg of ergotamine tartrate and 100mg of caffeine. Cafergot pills are the most convenient but least effective of the ergots. Dosage is one or two pills at the onset of headache, repeated every two hours as needed, with a maximum of four per day and ten per week. Side effects are similar to the preceding Ergomar discussion, with nausea and nervousness being common. Because of the caffeine, anxiety or nervousness is more common with Cafergot pills than with Ergomar. The same precautions discussed above in the Ergomar section also apply to Cafergot.

Compounded Cafergot Suppositories (only compounded available). These are less convenient but much more effective than the pills. Cafergot suppositories contain 2 mg of ergotamine tartrate and 100 mg of caffeine. The primary side effects are nausea and anxiety. The initial dose is one third or one half of a suppository and then the dose is titrated up or down, depending on the patient’s response. The dose may be repeated after one hour, up to a maximum of two suppositories per day and five per week. Some patients find that as little as one fifth of a suppository is all that they require. Side effects of Cafergot suppositories are the same as those of Cafergot pills. Nausea and anxiety always are limiting factors in the use of ergots.

Compounded Cafergot PB suppositories (only compounded available). These are similar but more effective than plain Cafergot suppositories. Cafergot PB contains 2 mg of ergotamine tartrate, 100 mg of caffeine, 60 mg of sodium pentobarbital, and 0.25 mg of 1-alkaloids of belladonna. Dosage is the same as for the plain Cafergot suppositories. Side effects are decreased, with less nausea and nervousness. Sedation may be a problem, however.

Dihydroergotamine (DHE). This is different from the other ergots in that it is primarily a venoconstrictor rather than an arterial constrictor. Since 1945, there have been relatively few serious side effects reported. DHE is available as an intramuscular (IM) or subcutaneous (SQ) injection or as a nasal spray (Migranal®). The usual dose is 1 mg IM or SQ, or one spray in each nostril to be followed in 10 to 20 minutes by one further spray of Migranal in each nostril. Side effects tend to be minimal with DHE, but nausea, a heat or flushed sensation, nasal stuffiness from the spray, or leg cramps may occur. Occasionally, chest heaviness is also seen. While DHE is not as effective as sumatriptan for cluster headache, DHE at times is the best alternative in patients who may be at some risk for cardiac disease. However, if patients have major risk factors such as uncontrolled hypertension or have known atherosclerotic heart disease, then DHE must be avoided. The usual maximum is three injections per day or two nasal sprays in each nostril per day. A new inhaled DHE, Levadex®, is expected to be approved shortly.

Abortive Analgesics for Cluster Headache

The abortive analgesic medications include the following;

  • Extra Strength Excedrin®
  • Naproxen
  • Butalbital compounds (Fiorinal® or Esgic®)
  • Opioids

In general, we do not want to have cluster patients rely on opioids. However, in some patients the pain is so severe and the first line therapies are not effective so that the use of opioids is justified. The milder approaches, such as Excedrin, should be utilized first, then the butalbital compounds, and finally the opioids.

Intranasal Lidocaine for Cluster Headache

Lidocaine spray, as a 4% lidocaine solution, has been used since the mid-1980s for cluster headache. I have found it only mildly effective for most patients and almost never adequate by itself. However, intranasal lidocaine does provide sufficient relief to warrant its use. Lidocaine is very safe with minimal side effects. When used in conjunction with ice and one of the first line abortives, the lidocaine spray can add 10 to 30% relief.

I put 4% topical lidocaine in a plastic nasal spray bottle. The patient is then instructed to lie in the supine position, extend their head back 30 to 45 degrees, turn the head toward the side of the pain and spray two or three sprays of the lidocaine intranasally. This may be repeated, but I usually limit the lidocaine sprays to six or eight in a 24-hour period. If the nasal passage is blocked, several drops of 0.5% phenylephrine may be used prior to the lidocaine.

Alternatively to the spray bottle, 1 ml of 4% topical lidocaine may be slowly dropped, via a dropper, into the nostril on the side of the pain. Side effects are minimal and may include numbness in the throat or, rarely, nervousness or tachycardia.

Last updated on: April 30, 2018
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