The standard TAC treatments – treatments for cluster headache, paroxysmal hemicrania, and SUNCT – differ considerably from the treatments which are appropriate for the cranial neuralgias.

Because there are important treatment decisions that must be made, a patient must receive an accurate differential diagnosis at the onset of their pain condition. Treating the wrong condition can be wholly ineffective and very disappointing, and sadly, that is the best possible outcome. Misdiagnosis and improper treatment can potentially create more pain for the patient than before treatment. Tragically, that increased pain could be permanent.

Accurate and complete diagnosis is imperative.

Cluster Headache

Effective management relies on shared responsibility between primary and secondary care, and all suspected cases should be initially referred for specialist neurological or headache assessment. Patients should be kept under long term follow-up and if possible be offered open appointments at times when bouts recur.

Standard analgesia is ineffective, and there is no evidence to support the use of non-steroidal anti-inflammatory drugs, acetaminophen, codeine, or opioids in the treatment of individual attacks. The mainstay of abortive cluster headache treatment consists of inhaled oxygen and parenteral triptans.

Oxygen

A recent double blind randomized placebo controlled crossover trial found that 78% of subjects were pain free after inhalation of 100% oxygen at 12 L/min for 15 minutes (P<0.001). Patients should continuously inhale oxygen at this rate for at least 15 minutes through a non-rebreathing facemask. Guidelines for oxygen use, including a prefilled home oxygen order form for doctors of patients in the United Kingdom, are provided on the website of the Organisation for the Understanding of Cluster Headache.

Triptans

Parenteral triptans have been shown to be an effective treatment for individual attacks, whereas orally administered triptans have not.

Preventive treatment

Preventive cluster headache treatment aims to suppress the attacks for the duration of the bout, or over longer periods in those with chronic cluster headache, with the fewest possible side effects.

Consensus evidence suggests that a tapering course of corticosteroids may temporarily reduce the frequency of headaches. A preventive agent, with longer latency until onset of action, should be started at the same time. The preventive drug of choice is verapamil.

Although evidence from controlled trials is limited, there is consensus that lithium may be a useful preventive treatment, even though it is generally of less use than verapamil.

Melatonin can be useful.

Other agents such as topiramate, sodium valproate, pizotifen, and gabapentin are occasionally used with some success, although data from clinical trials are limited.

Nerve blocks and infusions

Data from a recent randomized controlled trial support the injection of a mixture of local anesthetic and corticosteroid solution over the greater occipital nerve on the side of the pain.

Neuromodulation

The small proportion of people with chronic cluster headache who gain no meaningful benefit from preventive drugs should be considered for surgical intervention.  Occipital nerve stimulation involves the extracranial implantation of stimulating electrodes around the greater occipital nerve, situated below the scalp and overlying the occipital bones.

In 2006, a study was done that conclude that occipital nerve stimulation offers a safe, effective treatment option for cluster headache.1

Paroxysmal Hemicrania

One of the hallmarks of paroxysmal hemicrania (PH) is that the drug indomethacin provides complete and sustained relief.2


1. Brian Burns, MRCP, Laurence Watkins, FRCS, Prof Peter J Goadsby, MD.Treatment of medically intractable cluster headache by occipital nerve stimulation: long-term follow-up of eight patients. 2007. DOI: http://dx.doi.org/10.1016/S0140-6736(07)60328-6

2. Pareja JA, Caminero AB, Franco E, Casado JL, Pascual J, Sánchez del Río M. Dose, efficacy and tolerability of long-term indomethacin treatment of chronic paroxysmal hemicrania and hemicrania continua. Cephalalgia. 2001 Nov;21(9):906-10.

All other material excerpted from: BMJ. Clinical Review: Cluster Headache. 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2407

Rev. 07/17