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Treatments and drugs

By Mayo Clinic staff

There's no cure for cluster headaches. The goal of treatment is to help decrease the severity of pain, shorten the headache period and prevent the attacks.

Because the pain of a cluster headache comes on suddenly and may subside within a short time, over-the-counter pain relievers such as aspirin or ibuprofen (Advil, Motrin, others) aren't effective. The headache is usually gone before the drug starts working. Fortunately, other types of acute medication can provide some pain relief. Based on the latest studies, the therapies listed below have proved to be most effective for acute and preventive treatment of cluster headache.

Acute treatments
Fast-acting treatments available from your doctor include:

• Oxygen. Briefly inhaling 100 percent oxygen through a mask at a minimum rate of 7 liters a minute provides dramatic relief for most who use it. The effects of this safe, inexpensive procedure can be felt within 15 minutes. The major drawback of oxygen is the need to carry an oxygen cylinder and regulator with you, which can make the treatment inconvenient and inaccessible at times. Small, portable units are available, but some people still find them impractical. Be careful not to smoke or be near an open flame if you're using oxygen, due to the risk of explosion.

• Triptans. The injectable form of sumatriptan (Imitrex), which is commonly used to treat migraine, is also an effective acute treatment for cluster headache. The first use is often done while under medical observation. Some people may benefit from using sumatriptan in nasal spray form, but for most people this isn't as effective as an injection. Sumatriptan isn't recommended if you have uncontrolled high blood pressure or ischemic heart disease.

  Another triptan medication, zolmitriptan (Zomig), can be taken in nasal spray or tablet form for relief of cluster headache. This medication may be an option if you can't tolerate other forms of fast-acting treatments.

• Octreotide (Sandostatin, Octreotide Acetate). This drug, an injectable synthetic version of the brain hormone somatostatin, is an effective treatment for cluster headache and is safe if you have high blood pressure and ischemic heart disease.
• Local anesthetics. The numbing effect of local anesthetics, such as lidocaine (Xylocaine), may be effective against cluster headache pain when used intranasally.
• Dihydroergotamine. This medication derivative is available in intravenous, injectable and inhaler forms. Dihydroergotamine (D.H.E. 45, Migranal) is an effective pain reliever for some people with cluster headache. When administered intravenously, you'll need to go to a hospital or doctor's office to have an intravenous (IV) line placed in a vein. The inhaler form of the drug works more slowly.

Preventive treatments
Preventive therapy starts at the onset of the cluster episode with the goal of suppressing attacks. Determining which medicine to use often depends on the length and regularity of your episodes. Under the guidance of your doctor, the drugs can be tapered off once the expected length of the cluster episode ends.

• Calcium channel blockers. The calcium channel blocking agent verapamil (Calan, Verelan, others) is often the first choice for preventing cluster headache. Verapamil is often used in conjunction with other medications. Occasionally, longer term use is needed to manage chronic cluster headache. Constipation is a common side effect of this medication, as well as dizziness, nausea, fatigue, swelling of the ankles and low blood pressure.
• Corticosteroids. Inflammation-suppressing drugs called corticosteroids, such as prednisone, are fast-acting preventive medications. They belong to a general family of medicines called steroids. Your doctor may prescribe corticosteroids if your cluster headache condition has only recently started or if you have a pattern of brief cluster periods and long remissions. Although corticosteroids are an excellent short-term option, serious side effects make them inappropriate for long-term use.
• Lithium carbonate. Lithium (Lithobid), which is used to treat bipolar disorder, is also effective in preventing chronic cluster headache. Side effects include tremor, increased urination and diarrhea. Your doctor can adjust the dosage to minimize side effects. While you're taking this medication, your blood will be drawn at regular intervals to check for the development of more-serious side effects, such as kidney damage.
• Nerve block. Injecting a numbing agent (anesthetic) and corticosteroid into the area around the occipital nerve, located at the back of your head, can prevent pain messages from traveling along that nerve pathway. The occipital nerve converges with the trigeminal nerve, which connects to all the pain-sensitive structures in your skull. An occipital nerve block can be useful for temporary relief until long-term preventive medications take effect.
• Ergots. Ergotamine (Ergomar), available as a tablet that you place under your tongue, can be taken before bed to prevent nighttime attacks. Self-injected dihydroergotamine also may be helpful. Ergot medications are effective, but can't be combined with triptans and can only be used for brief periods of time.
• Melatonin. Studies show that 10 milligrams of melatonin taken in the evening might reduce the frequency of cluster headache.

Other preventive medications used for cluster headache include anti-seizure medications such as divalproex (Depakote) and topiramate (Topamax).

Surgery
Rarely, surgery is recommended for people with chronic cluster headache who don't respond well to aggressive treatment or who can't tolerate the medications or their side effects.

Surgical procedures for cluster headache attempt to damage the nerve pathways thought to be responsible for pain, most commonly the trigeminal nerve that serves the area behind and around your eye. The long-term benefits of surgery are disputed, however, and because of the possible complications — including muscle weakness in your jaw or sensory loss in certain areas of your face and head — it's rarely considered.

Newer treatments
As scientists learn more about the causes of cluster headache, they're able to develop more-selective treatments for the condition. One treatment in development is the use of a device to stimulate the occipital nerve, which influences the trigeminal nerve. To treat people with frequent cluster headaches, researchers are testing a stimulator — a pacemaker-sized device that sends impulses via electrodes — that is implanted over the occipital nerve. Several small studies of implanted occipital nerve stimulators found that the devices reduced chronic headache pain in some people, and the devices were well tolerated and appeared to be very safe.

Similar research is under way using an implanted stimulator in the hypothalamus, the area of the brain associated with the timing of cluster periods. Deep brain stimulation of the hypothalamus may provide relief for people with severe, chronic cluster headaches.

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