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Treatments and drugs
By Mayo Clinic staffThere's no cure for cluster headaches. The goal of treatment is to help decrease the severity of pain and shorten the headache period.
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. Treatment of cluster headache is focused more on prevention, with more medication options available to choose from.
Acute treatments
Fast-acting treatments available from your doctor include:
- Oxygen. Briefly inhaling 100 percent oxygen through a mask at a rate of 7 to 10 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. Sometimes, oxygen may only delay rather than stop the attack, and pain may return.
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Triptans. The injectable form of sumatriptan (Imitrex), which is commonly used to treat migraine, also is an effective acute treatment for cluster headache. 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 form for relief of cluster headache. This medication may be an option if you can't tolerate other forms of fast-acting treatments.
- 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, the drug requires you 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.
- Octreotide (Sandostatin, Sandostatin LAR). 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 in the form of nasal drops.
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. Candidates for surgery must have headaches only on one side of the head because the surgery can be performed only once.
Several types of surgery have been used to treat cluster headache. These procedures attempt to damage the nerve pathways thought to be responsible for pain. However, residual muscle weakness in your jaw or sensory loss in certain areas of your face and head may result. Surgical options include:
- Conventional surgery. Using a conventional invasive procedure, your surgeon cuts part of the trigeminal nerve — the nerve that serves the area behind and around your eye — with a scalpel or uses small burns to destroy part of the nerve. This form of surgery can provide relief, but has serious risks to the eye. This is no longer a procedure of first choice.
- Glycerol injection. An injection of glycerol into the facial nerves can provide immediate relief of symptoms with less risk than other surgical procedures.
Newer treatments
As scientists learn more about the causes of cluster headache, they're able to develop more-selective treatments for the condition. One development that shows promise 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, including one by Mayo Clinic researchers, 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.
Preventive medicine
Whenever a cluster period starts, you'll likely start taking a long-term medication, often accompanied by a short-term medication. After your headaches are under control, you'll likely discontinue use of the short-term medication but continue with the long-term drug.
Short-term medications can help prevent headache attacks during the period of time it takes for one of the long-term drugs to become effective.
- 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.
- Ergotamine. Ergotamine (Ergomar, others), available as a tablet that you place under your tongue or available as a rectal suppository, can be taken before bed to prevent nighttime attacks. Ergot medications are effective, but can't be combined with triptans.
- 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.
Long-term medications are taken during the entire cluster period. Some people with chronic cluster headache may need to take two or more long-term medications simultaneously.
- Calcium channel blockers. The calcium channel blocking agent verapamil (Calan, Verelan, others) is often the first choice for preventing cluster headache. Sometime after your cluster period ends, the use of this medication is gradually tapered and discontinued under your doctor's direction. 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.
- Lithium carbonate. Lithium (Lithobid, Eskalith, others), 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.
Other preventive medications used for cluster headache include anti-seizure medications such as divalproex (Depakote) and topiramate (Topamax).
- Bajwa ZH, et al. Patient information: Headache causes and diagnosis in adults. http://www.uptodate.com/home/index.html. Accessed Dec. 19, 2008.
- Goetz CG. Headache. In: Goetz CG. Textbook of Clinical Neurology. 3rd ed. Philadelphia, Pa.: Saunders Elsevier; 2007. http://www.mdconsult.com/das/book/body/115317111-2/787037600/1488/451.html. Accessed Dec. 29, 2008.
- Leroux E, et al. Cluster headache. Orphanet Journal of Rare Diseases. 2008;3:20.
- Headache: Hope through research. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/headache/detail_headache.htm?css=print. Accessed Dec. 29, 2008.
- Bajwa ZH, et al. Approach to the patient with headache syndromes other than migraine. http://www.uptodate.com/home/index.html. Accessed Dec. 19, 2008.
- Treatment of primary headache: Cluster headache. National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?doc_id=6582&nbr=004142&string=clus. Accessed Jan. 2, 2009.
- Bajwa ZH, et al. Patient information: Headache treatment in adults. http://www.uptodate.com/home/index.html. Accessed Dec. 19, 2008.
- Magis D, et al. Neurostimulation in Chronic Cluster Headache. Current Pain and Headache Reports. 2008;12:145.
- Rossi P, et al. Use of complementary and alternative medicine by patients with cluster headache: Results of a multi-centre headache clinic survey. Complementary Therapies in Medicine 2008;16:220.
- Swanson JW (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 12, 2009.
