Cluster Headache is a very severe form of primary headache disorder with a population, one-year prevalence of about 0.1 %. Classified as a Trigeminal Autonomic Cephalagia (TAC) (1), it is probably the second most common form of primary headache encountered by neurologists or headache specialists. Cluster headache (CH) comes in two dominant forms: episodic CH, in which there are breaks of a month or more without therapy (80% of patients), and chronic CH in which such breaks are not seen (20% of patients) (2).
Acute Attack Treatment
CH attacks are typically short—from 30 to 180 minutes, and often peak rapidly—requiring a treatment with quick onset. Medication overuse headache can be seen in CH patients, typically if they have a co-existent history or family history of migraine, and when largely ineffective treatments are employed for acute attacks, such as oral triptans, acetaminophen, and opiate receptor agonist analgesics.
Oxygen: Inhaled oxygen,100% at ten to twelve L/min for 15 minutes is an effective, safe treatment of acute cluster headache (RCT).
Triptans: Sumatriptan six mg subcutaneous, sumatriptan 20mg intranasal, and zolmitriptan five mg intranasal are effective in the acute treatment of cluster headache (RCT). Three doses of zolmitriptan in twenty-four hours are acceptable. There is no evidence to support the use of oral triptans in CH.
Dihydroergotamine: one mg IM is effective in the relief of acute attacks of CH. The intranasal form seems less effective, although some patients benefit from its use.
Lidocaine: topical lidocaine nasal drops may be used to treat acute attacks of CH. The patient lies supine with the head tilted backwards toward the floor at 30 degrees, and turned to the side of the headache. A nasal dropper may be used and the dose (one mL of 4% lidocaine) repeated once after 15 minutes.