Code of conduct
In contrast to the treatment of migraine and tension-type headaches, non-pharmacological therapy strategies are of secondary importance in cluster headaches. Although the exact nature of the relationship between cluster headaches and nicotine consumption is still unclear, nicotine consumption is considered the only factor that an affected person can influence to prevent the transition of an episodic cluster headache to the chronic form.
Behavioral guidelines for cluster headaches
Sensible:
- Avoid trigger factors during active cluster periods (alcohol, nitrates, stays at high altitudes)
- General abstinence from nicotine consumption
Ineffective:
- Relaxation techniques
- Stress management techniques
- Physiotherapeutic or physical measures
- acupuncture
Attack therapy
Oxygen at clusters
In the vast majority of patients, opioid and non-opioid analgesics are ineffective in the treatment of cluster headache attacks. Only inhalation of 100% oxygen and subcutaneous injection of 6 mg sumatriptan have proven reliably effective.
In the treatment of an attack, inhaling pure oxygen via a face mask is particularly gentle and effective. Proper handling and information are essential. A portable oxygen cylinder can be prescribed. An effective alternative is sumatriptan injection, which can be self-administered subcutaneously using an autoinjector.
- Oxygen (inhalation of 100% O2, at least 10l/min for 10 minutes with a face mask)
- Sumatriptan (6 mg subcutaneously)
Second choice
- Sumatriptan (20 mg nasal)
- Zolmitriptan (2.5 – 5 mg oral, 5 mg nasal)
Third choice
- Spray lidocaine (4% solution) into the nostril on the side of the pain
oxygen
Inhalation of 100% oxygen at a rate of 7 liters per minute for approximately 15 minutes alleviates or terminates attacks in about two-thirds of patients within 15 minutes. Application at the onset of an attack is particularly effective. The use of a face mask is recommended for patients with nasal congestion or rhinorrhea. The mechanism of action appears to be acute vasoconstriction of intracerebral vessels. The advantages of oxygen include its extremely good tolerability, the absence of interactions with medications used for the prophylaxis of cluster headaches, and the unlimited repetition of treatment for recurrent attacks during the same day. The most significant disadvantage, despite the availability of portable oxygen cylinders, is its limited practicality. Furthermore, unlike sumatriptan, oxygen has no prophylactic effect immediately after successful administration.
Sumatriptan sc.
Subcutaneous administration of sumatriptan 6 mg via autoinjector or pre-filled syringe is by far the most effective treatment for cluster headache attacks. Approximately 75% of treated attacks subside within 15 minutes, with the effect often beginning within just a few minutes. Long-term studies have shown that this excellent efficacy persists throughout the entire course of treatment. Medication-induced headaches have not been observed. Sumatriptan is generally very well tolerated by cluster headache patients, even in reported cases of overdose, with up to 8 injections administered within 24 hours. Theoretically, the maximum dosage is limited to 2 x 6 mg within 24 hours. It is important to note that sumatriptan must not be combined with methysergide or ergotamine tartrate for cluster headache prophylaxis. Furthermore, the general contraindications for the use of sumatriptan must be observed.
The nasal formulations of sumatriptan (20 mg) and zolmitriptan (5 mg) have also proven effective in controlled studies. However, compared to subcutaneous sumatriptan, the onset of action is significantly delayed and the overall efficacy is lower. Instilling four sprays of a 4% lidocaine solution into the nostril on the affected side, with the head tilted back at 45° and rotated 30° towards the painful side, can provide pain relief in individual cases. However, in a larger open-label case series, the effect was poor. Furthermore, the onset of action appears to be delayed compared to subcutaneous sumatriptan and oxygen.