Treatment of Cluster Headache Attacks

Acute cluster headaches are severe

The pain is so severe that some cluster patients have been known to kill themselves because of the attacks. There are treatments available to treat a cluster headache when it is occurring.

Sphenopalatine Ganglia Block (SPG Block)

SPG block is now possible using a device that is placed by a physician througth the nose. One of these devices is Sphenocath™. With this device, lidocaine, a local anethetic is used to produce the block. It also blocks the 2nd branch of the trigeminal nerve. This treatment not only treats an acute headache but appears to help prevent future headaches. There is limited controlled data at this time. Most insurances will pay for this therapy at this time. This therapy can safely be done during pregnancy. Bellaire Neurology currently offers this therapy to patients.

Oxygen Therapy

Oxygen is the long-standing treatment for an acute cluster attack. While it is not useful for everyone, for those that do benefit, it becomes the mainstay of acute headache therapy. Unless you have lung disease, (or an open flame), it is essentially side effect free. It is critically important, however, that the oxygen treatment attempt is done properly. First, use oxygen tanks and not an oxygen concentrator. Oxygen concentrators provide a lower percentage of oxygen in the air (typically 90%) but most importantly, cannot deliver the high flow rates that are required for cluster patients. The mask must be a non-rebreather mask with an excellent seal on the face. In this way, the patient will receive a very high concentration of oxygen. Finally, a high flow rate (start at 15 liters) per minute) should be used. If the oxygen works well, you can experiment with decreasing flow rates to find the flow rate that you need. Many patients only need a 7 liter flow rate and the tanks you get will last twice as long at 7.5 liters per minute than 15 liter per minute. Using a demand valve with early hyperventilation may improve the effectiveness of oxygen {Demand valve oxygen: a promising new oxygen delivery system for acute treatment of cluster headaches. Rozen TD, Fishman RS, Pain Med 2013 Apr;14(4):455-9 Epub 2013 Jan 31}.

Gammacore

Gammacore® is an electronic device that delivers current to the Vegas Nerve. It is used both during acute attacks.  It is used to help prevent attacks.  The device worked for episodic cluster headache but not chronic cluster headache.

SPG Stimulation

Approved in Europe, SPG stimulation by a device made by Autonomic Technologies appears to potentially treat the painful attack along with preventing future attacks. {Stimulation of the sphenopalatine ganglion for cluster headache treatment. US studies are in progress at the time of this writing (August 2014). {Pathway CH-1: A randomized, sham-controlled stuy. Schoenen J, et.al. Cephalgia 33(10) 816-30}.  Unfortunately, the company went bankrupt and the device is not currently available.  Dr. Loftus hope it returns to market soon.

Triptans

The faster acting triptans – sumatriptan injections and zolmiptriptan nasal spray are both approved to treat acute cluster.  The frequency of cluster headache and the inability to get enough zolmitriptan nasal sprays and sumatriptan injections limit its use.

Oral triptans can sometimes shorten a cluster attack.  Many oral triptans are very cheap and therefore patients can afford to pay for their daily use.

Dihydroergotamine

Dihydroergotamine (DHE) injections and nasal spray (Trudhesa® and Migranal®) can be used for acute cluster headaches.  Its long half life also makes it useful to treat the first acute headache of the day and then having it prevent additional attacks.

Of course, treating acute attacks should be only part of the initial plan in treating patients with acute cluster headaches. Physicians that do not start the patient on a cluster headache prevention agent are not treating the entire disease.

Source for Gammacore data:
Nesbitt , AD. et al., Non-invasive vagus nerve stimulation for the treatment of cluster headache: a case series. The Journal of Headache and Pain 2013,1(Suppl 1):P231.