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Q. What is the recommended treatment for cluster headaches?
A. Cluster headaches are often termed suicide headaches because of the severity of the pain it causes.
These headaches most often are one-sided and occur near the eye and may also cause a runny/stuffy nose, tearing and restlessness. Thankfully, the duration of most cluster headaches is short (15 minutes to 3 hours) however, as the name implies, the headaches appear in clusters which can be as infrequent as once every two days or up to eight times in a day. An episode of a cluster headache can typically last as long as 6-8 weeks.
People that suffer from chronic cluster headaches experience less than 1 month a year headache free. Since the pain appears very rapidly and can be quite debilitating, it is best to look at medications that offer a quick onset of action.
Oxygen and tryptans are considered first line treatments for cluster headaches. Oxygen offers a very quick onset of action (15 minutes) and a high efficacy (~75%) but is limited to having access to a medical supplier to obtain an oxygen tank and is not as portable as the other treatments.
Injectable sumatriptan (Imitrex) offers a similar quick onset and efficacy but is restricted to 12mg (2 doses) daily and is limited to people that are comfortable with giving themselves a needle.
Unfortunately, all tryptans, regardless of dosage form, are contra-indicated in people that also suffer from cerebral vascular disease. Intranasal tryptans (sumatriptan and zolmitriptan) have an onset of about 30 minutes and an efficacy rate about 49-80%. Though they are not as quick acting as the oxygen or injectable sumatriptan, they are still much quicker than the oral tablets which are not considered an optimal choice for cluster headaches due to their longer onset of action. The intranasal tryptans offer an alternative for people that do not wish to use an injection.
Corticosteroids (prednisone, dexamethasone) can be used in the management of preventing chronic cluster headaches. Due to their quick action, they can be useful while waiting for the preventative therapy to take effect.
Phophylaxis can be considered if two or more headaches are experienced each day during an episode. Verapamil is the first line choice and has an onset of action of 72 hours and can take 2-3 weeks to gain maximum effect. Therefore, it would only be considered for chronic cluster headaches that continue for many weeks on end.
Lithium has also been used as a prophylaxis but is limited to its much longer onset of action (10-15 days). Topiramate has been used in conjuction with verapamil in order to avoid using higher verapamil doses.
Lastly, there is limited evidence to support it but melatonin can be used either alone or along with other treatments. There is some thought that melatonin levels are lower in people during an episode of cluster headaches.
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Sunday, November 20, 2016