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Triptans and oxygen effective for treating acute cluster headaches

Clinical Question:
What treatments are effective in treating and preventing acute cluster headaches?

Bottom Line:
The existing research on treating acute cluster headaches is limited to a small number of small studies. Based on the existing research, patients with acute cluster headaches should be treated with 100% oxygen (SORT A) or intranasal triptans (SORT A). The data for preventing cluster headaches is too limited to be able to draw any conclusions. (LOE = 2a-)

Reference:
Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology 2010;75(5):463-473.  [PMID:20679639]

Study Design:
Systematic review

Funding:
Unknown/not stated

Setting:
Outpatient (specialty)

Synopsis:
These authors systematically searched MEDLINE and EMBASE for prospective, double-blind, parallel-group or crossover, randomized controlled trials comparing active medication with placebo in the treatment or prevention of cluster headaches. The authors don't describe looking for unpublished studies. Two authors independently determined the inclusion of studies and extracted the data. They resolved any discrepancies by discussion. Ultimately, they identified 27 relevant studies. The studies ranged in size from 8 patients to 168 patients. With small studies, the results are not very robust and future larger trials may swamp their findings. And since the researchers only found a small number of small studies, the potential for publication bias is worrisome. Acute management: Three trials evaluated sumatriptan via various routes, each showing statistical improvement over placebo. Additionally, 3 studies evaluated zolmitriptan (oral and nasal spray). In these studies, intranasal triptans were effective in aborting acute cluster headaches. However, oral zolmitriptan was only effective in patients with episodic but not chronic cluster headaches. Two studies evaluated 100% oxygen. In 1 study, oxygen at 6 L per minute for 15 minutes provided "substantial" relief for 56% of patients compared with 7% of those treated with placebo (number needed to treat [NNT] = 2). In the other study, 78% of patients treated with oxygen at 12 L per minute were pain free after 15 minutes compared with 20% of patients treated with air (NNT = 2). The authors found a single, lower-quality trial that showed intranasal cocaine and intranasal lidocaine each took about 30 minutes to provide complete relief of acute headaches compared with 1 hour for saline. In a single, low-quality, crossover study, octreotide provided relief after 30 minutes to 52% of patients compared with 36% of patients who received placebo (NNT = 7). Several studies evaluated ergot alkaloids, somatostatin, and prednisone. The overall quality of the studies, however, was poor enough to prevent us from knowing if they were truly effective. Prevention: One small, high-quality study found that civamide (not available in the United States) used intranasally for 7 days caused greater reduction in the rate of headaches (56% absolute reduction) than placebo (26% absolute reduction). We have no long-term data and the rate of side-effects was fairly high: nasal burning (78%), lacrimation (50%), pharyngitis (44%), and rhinorrhea (33%). A single high-quality study with 23 patients found that 85% of patients receiving suboccipital steroid injections (12.46 mg betamethasone dipropionate and 5.26 mg betamethasone disodium phosphate mixed with 0.5 mL lidocaine 2%) had no further attacks within 72 hours compared with none of the patients receiving placebo. Single studies found that neither sumatriptan nor sodium valproate were better than placebo in preventing headaches. Lower-quality studies suggest that verapamil, lithium, and melatonin may also prevent cluster headaches. Based on the existing research (albeit, generally of poorer quality), the following do not appear to be helpful in preventing cluster headaches: misoprostol, hyperbaric oxygen, cimetidine, chlorepheniramine, capsaicin, prednisone, and nitrate tolerance.

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