Cluster Headache

Author: Michelle Blanda, MD; Chief Editor: Howard A Crystal, MD

Updated: Oct 18, 2012Background

Cluster headache (CH), also known as histamine headache, is a primary neurovascular
primary headache disorder, the pathophysiology and etiology of which are not well
understood.[1] As the name suggests, CH involves a grouping of headaches, usually over a
period of several weeks. According to the diagnostic criteria developed by the
International Headache Society (IHS), CH has the following characteristics [2, 3] :

The patient experiences attacks of severe or very severe, strictly unilateral pain
(orbital, supraorbital, or temporal pain) that last 15-180 minutes and occur from
once every other day to 8 times a day
The attacks are associated with 1 or more of the following (all ipsilateral):
conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and
facial sweating, miosis, ptosis, or eyelid edema

CH may be usefully classified into 2 main forms as follows:

Episodic CH, in which at least 2 cluster phases lasting 7 days to 1 year are
separated by a cluster-free interval of 1 month or longer
Chronic CH, in which the clusters occur more than once a year without remission
or the cluster-free interval is shorter than 1 month

Pathophysiology
The underlying pathophysiology of CH is incompletely understood.[4, 5] The periodicity of
the attacks suggests the involvement of a biologic clock within the hypothalamus (which
controls circadian rhythms), with central disinhibition of the nociceptive and autonomic
pathwaysspecifically, the trigeminal nociceptive pathways. Positron emission
tomography (PET) and voxel-based morphometry have identified the posterior
hypothalamic gray matter as the key area for the basic defect in CH.[1] See the images
below.

Cluster headache: Functional imaging shows activation of

specific brain areas during pain. Courtesy of Wikipedia Commons.

Cluster headache (CH): Voxel-based morphometry (VBM)

structural imaging shows specific brain area of CH patients' (hypothalamus) being
different to non-CH patients' brains. Courtesy of Wikipedia Commons.
Altered habituation patterns and changes have been observed within the trigeminal-facial
neuronal circuitry secondary to central sensitization, in addition to dysfunction of the
serotonergic raphe nuclei-hypothalamic pathways (though the latter is not as striking as in
migraine). Functional hypothalamic dysfunction has been confirmed by abnormal
metabolism based on the N-acetylaspartate neuronal marker in magnetic resonance
spectroscopy.[6]
Substance P neurons carry sensory and motor impulses in the maxillary and ophthalmic
divisions of the trigeminal nerve. These connect with the sphenopalatine ganglion and
interior carotid perivascular sympathetic plexus. Somatostatin inhibits substance P and
reduces the duration and intensity of CH.
Vascular dilatation may play a role in the pathogenesis of CH, but blood flow studies are
inconsistent. Extracranial blood flow (hyperthermia and increased temporal artery blood
flow) increases, but only after the onset of pain. Vascular change is considered secondary
to primary neuronal discharge.
Although the evidence supporting a causative role for histamine is inconsistent, cluster
headaches may be precipitated with small amounts of histamine. Antihistamines do not
abort cluster headaches. Increased numbers of mast cells have been found in the skin of
painful areas of some patients, but this finding is inconsistent.

Etiology
The exact cause of CH is unknown. The disorder is sporadic, though rare cases of an
autosomal dominant pattern within a single family have been reported.
Several factors have been shown to provoke CH attacks. Subcutaneous injection of
histamine provokes attacks in 69% of patients. Stress, allergens, seasonal changes, or
nitroglycerin may trigger attacks in some patients. Alcohol induces attacks during a
cluster but not during remission. About 80% of CH patients are heavy smokers, and 50%
have a history of heavy ethanol use.
Risk factors for CH include the following:

Male sex
Age older than 30 years
Small amounts of vasodilators (eg, alcohol)
Previous head trauma or surgery (occasionally)

Epidemiology
The exact prevalence of CH in the United States is unknown; Kudrow estimated it to be
0.4% in men and 0.08% in women.[7] Compared with classic migraine, CH is relatively
uncommon, with an incidence equivalent to only 2-9% of that of migraine. Prevalence in
males is 0.4-1%. In an extensive study of 100,000 inhabitants of the republic of San
Marino, the prevalence was 0.07%. The incidence of CH in the United Kingdom is
equivalent to that of multiple sclerosis.

Age-, sex-, and race-related demographics

CH usually begins in middle adult life (eg, in the 30s); however, it has been reported in
patients as young as 1 year and as old as 79 years.
CH is more common in males than in females; the male-to-female ratio was 6:1 in the
1960s but is now closer to 2:1. Presentations in females may differ from those in males,
according to data from the United States Cluster Headache Survey.[8] For example,
women tend to develop CH at an earlier age and are also more likely to exhibit a second
peak of CH incidence after the age of 50.
Racial and ethnic differences have not been well studied, but CH may be slightly more
prevalent in African Americans and may be underdiagnosed in black women.

Prognosis
Generally, CH is a lifelong problem. Potential outcomes include the following:

Recurrent attacks

Prolonged remissions
Possibility of transformation of an episodic cluster to a chronic cluster and vice
versa

About 80% of patients with episodic CH maintain the episodic form of the disorder. In 413%, episodic CH eventually transforms into chronic CH. Intermediate (mixed) forms
may also develop. Prolonged, spontaneous remissions occur in as many as 12% of
patients, particularly in those with episodic CH. Chronic CH is more relentless and may
persist in this form in as many as 55% of cases. Less frequently, chronic CH may remit
into an episodic form.
No reported mortality is directly associated with CH. However, patients with CH are at
increased risk for self-injury during attacks, suicide attempts, alcohol use (and other
forms of substance abuse), cigarette smoking, and peptic ulcer disease. Suicides have
been reported in cases where attacks are frequent and severe. The intensity of the attacks
often leads CH patients to miss time from activities such as work or school. Medications
used may have side effects, including the unmasking of coronary artery disease.
Pharmacologic intervention may play a part in the transformation of chronic CH into the
episodic form; otherwise, it does not influence outcome. Late onset of the disorder, male
sex, and previous episodic CH all predict a less favorable course.

Patient Education
Patients should be educated regarding the need to avoid known precipitants of CH. In
addition, they should be instructed to avoid high altitudes.
For patient education resources, see the Headache Center, as well as Causes and
Treatments of Migraine and Related Headaches, Cluster Headache, Alternative and
Complementary Approaches to Migraine and Cluster Headaches, Cluster Headache
FAQs, and Understanding Migraine and Cluster Headache Medications

History
Attacks of cluster headache (CH) are typically short and occur with a clear periodicity,
particularly during sleep or early morning hours, usually corresponding with onset of
rapid eye movement (REM) sleep.[5] Unlike migraine, CH is not preceded by aura and is
not usually accompanied by symptoms such as nausea, vomiting, photophobia, or
osmophobia. Typically, a patient experiences 1-2 cluster periods per year, each lasting 2
weeks to 3 months.
The International Headache Society (IHS) classifies CH as episodic or chronic on the
basis of duration as follows[3] :

Episodic CH occurs in periods lasting from 7 days to 1 year; cluster attacks are
separated by pain-free intervals at least 1 month long

Chronic CH persists for more than 1 year either without remission or with
remissions shorter than 1 month; it is further divided into 2 subcategories, chronic
CH from onset and chronic CH evolving from episodic CH

The pain of CH is manifested as follows:

Character - Excruciating, stabbing, sharp, and lancinating (as if the eye is being
pushed out), rather than throbbing
Location Unilateral, in the periorbital, retro-orbital, or temporal regions, though
pain sometimes radiates to the cheek, jaw, occipital, and nuchal regions; the pain
tends to remain on the same side during the cluster period but in rare cases may
switch sides
Distribution - First and second divisions of the trigeminal nerve; approximately
18-20% of patients complain of pain in the extratrigeminal areas (eg, the back of
the neck, along the carotid artery)
Onset Sudden, peaking in 10-15 minutes
Duration - 5 minutes to 3 hours per episode
Frequency - May occur 1-8 times a day for as long as 4 months (often nocturnal)
Periodicity - Circadian regularity in 47%
Remission - Long symptom-free intervals occur in some patients; the length of
these remissions averages 2 years but may range from 2 months to 20 years

Pain is accompanied by various cranial parasympathetic symptoms, including the

following[5] :

Ipsilateral lacrimation (84-91%) or conjunctival injection

Nasal stuffiness (48-75%) or rhinorrhea
Ipsilateral eyelid edema
Ipsilateral miosis or ptosis
Ipsilateral forehead and facial perspiration (26%)

Alcoholic products and tobacco may precipitate an attack. Other triggers include hot
weather, watching television, nitroglycerin, stress, relaxation, extreme temperatures,
glare, allergic rhinitis, and sexual activity.
During an attack of CH, as many as 90% of patients may become agitated and extremely
restless. They do not like to lie down to rest; instead, they prefer to pace or move around.
In desperation, patients may rock, sit, pace, bang themselves against a hard surface,
scream in pain, or crawl on the floor.
Structural lesions have been described with CH and should be suspected if the
presentation is atypical. Atypical features may include the following:

Absence of a periodic pattern

Residual headache between exacerbations
Bilaterality

Incomplete or minimal response to standard therapy

Presence of lateralizing findings on examination (other than Horner syndrome)

Physical Examination
Physical examination findings should be normal, except for certain findings that serve as
hallmarks of CH. These accompanying findings are consistent with ipsilateral autonomic
features characterized by cranial parasympathetic activation and sympathetic
hypofunction. The presence of other abnormalities suggests another etiology for the
headache.
Characteristic findings include the following:

Distinctive facial appearance - Leonine facies, multifurrowed and thickened skin

with prominent folds, a broad chin, vertical forehead creases, and nasal
telangiectasias
Parasympathetic overactivity - Ipsilateral lacrimation, conjunctival injection,
rhinorrhea or congestion
Ocular sympathetic paralysis - Mild Horner syndrome (eg, ptosis, miosis, and
anhidrosis), which may persist between attacks
Bradycardia
Facial flushing or pallor
Scalp and facial tenderness
Ipsilateral carotid tenderness (in some patients)

Patients often are in severe distress. They may lower the head and press on the site of
pain, sometimes crying or screaming. Physical exercise may afford a degree of relief. In
cases of especially severe or intolerable pain, patients may even threaten suicide.

Diagnostic Considerations
In addition to the conditions listed in the differential diagnosis, other problems to be
considered include the following:

Acute hypertension (including response to pressors, pheochromocytoma, and

preeclampsia)
Allergen exposure
Arteriovenous malformations
Brainstem syndromes
Cerebral venous thrombosis[9]
Connective tissue disorder (eg, systemic lupus erythematosus)
Cyclical migraine
Eye disorders (eg, acute optic neuritis and acute glaucoma)
Hemicrania (continual or paroxysmal)
Ice-pick headaches
Intracranial neoplasm

Intracranial trauma
Interior carotid artery dissection
Intermittent hydrocephalus
Metastatic lung carcinoma
Nasopharyngeal carcinoma
Malignant and nonmalignant pain syndromes
Medication adverse effect
Pituitary tumors
Raeder paratrigeminal syndrome
Sleep apnea headache
SUNA (short-lasting unilateral neuralgiform headache attacks with cranial
autonomic symptoms)
SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival
injection and tearing)
Vertebral artery aneurysm

Differential Diagnoses

Anisocoria
Basilar Artery Thrombosis
Brainstem Gliomas
Cavernous Sinus Syndromes
Craniopharyngioma
Headache: Pediatric Perspective
Herpes Zoster
Intracranial Hemorrhage
Migraine Variants
Persistent Idiopathic Facial Pain
Pituitary Tumors
Postherpetic Neuralgia
Sinusitis Imaging
Subarachnoid Hemorrhage
Tolosa-Hunt Syndrome
Trigeminal Neuralgia

Approach Considerations
The diagnosis of cluster headache (CH) is based on historical and physical findings. A
history of attacks that occur with the characteristic periodicity and rhythmicity is the key
to the diagnosis. Laboratory studies are not of particular value in this regard.
Imaging studies, though not diagnostic, are useful for excluding other potential causes of
headache in selected patients. Neuroimaging with assessment of the intracranial and
cervical vasculature and the sellar and paranasal region is recommended in all patients
with atypical presentations of trigeminal autonomic headaches.

Approach Considerations
Pharmacologic management of cluster headache (CH) may be classified into 2 general
approaches as follows:

Abortive/symptomatic (eg, oxygen, triptans, ergot alkaloids, and anesthetics)

Preventive/prophylactic (eg, calcium channel blockers, mood stabilizers, and
anticonvulsants)

Olanzapine[10] and kudzu[11] have also been used to treat CH, but their effectiveness has not
been determined. Antihistamines, such as chlorpromazine, do not appear to be helpful in
relieving CH symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given
for pain relief.
Various procedures may be performed on trigeminal nerve or autonomic pathways,
including alcohol injections and section or avulsion of nerves for chronic refractory
cases. Surgical treatment may be initiated if the patient has contraindications to
medications or if medications are not effective; it is employed only in strictly unilateral
cases. Radiofrequency (RF) thermocoagulation of the trigeminal ganglion has had
promising results in some patients with intractable pain.
Treatment guidelines are available from the American College of Emergency Physicians
and the National Headache Foundation.[12, 13] Neurologic consultation may be useful if the
diagnosis is in doubt or for management of difficult cases.

Management of pregnant patients

CH is rare during pregnancy, but when it does occur, episodes tend to have the same
character and severity as in nonpregnant patients.[14] Treatment options for pregnant
women are poorly documented. The first line of treatment is pure oxygen via a
nonrebreather mask (see image below). Triptans and ergot alkaloids should be avoided.
The use of selected preventive medications, which are rated pregnancy category B,
should be discussed thoroughly with the patient and her obstetrician.[15]

Non-rebreather oxygen mask with reservoir for the acute

treatment of cluster headache. Courtesy of Wikipedia Commons.

Pharmacologic Therapy
Abortive agents are given to stop or reduce the severity of an acute CH attack, whereas
prophylactic agents are used to reduce the frequency and intensity of individual headache
exacerbations. In view of the fleeting, short-lived nature of the attacks, effective
prophylaxis should be considered the cornerstone of management. The prophylactic
regimen should start at the onset of a CH cycle and continue until the patient is headachefree for at least 2 weeks. The agent then may be tapered slowly to prevent recurrences.

Abortive agents
Oxygen (8 L/min for 10 minutes or 100% by mask) may abort the headache if used early.
[16, 17]
The mechanism of action is unknown.
5-Hydroxytryptamine-1 (5-HT1) receptor agonists, such as triptans or ergot alkaloids with
metoclopramide, are often the first line of treatment. Stimulation of 5-HT1 receptors
produces a direct vasoconstrictive effect and may abort the attack.
The triptan that has received the most study in the setting of CH is sumatriptan.[13, 16, 17]
Subcutaneous injections can be effective, in large part because of the rapidity of onset.
Studies have indicated that intranasal administration is more effective than placebo but
not as effective as injections; there is no evidence that oral administration is effective. A
typical dose is 6 mg subcutaneously, which may be repeated in 24 hours. Nasal spray (20
mg) may also be used.
Other triptans that may be considered for abortive treatment of CH are zolmitriptan,
naratriptan, rizatriptan, almotriptan, frovatriptan, and eletriptan. In addition, researchers
have begun to explore the possibility of using triptans for prophylaxis of CH.[18]
Dihydroergotamine can be an effective abortive agent. It is commonly given
intravenously (IV) or intramuscularly (IM) and may be self-administered; it can also be
given intranasally (0.5 mg bilaterally).[17] Dihydroergotamine tends to cause less arterial
vasoconstriction than ergotamine tartrate and is more effective when given early in a
cluster attack.
Parenteral opiates may be used if relief is inadequate. The short-lived and unpredictable
character of CH precludes effective use of oral narcotics or analgesics, though oral
regimens may sometimes be helpful for residual soreness. Abuse potential does exist.
Narcotics are not generally recommended for aborting CH.
Intranasal civamide and capsaicin have yielded good results in clinical trials. Application
of capsaicin to the nasal mucosa led to a clinically significant decrease in the number and
severity of cluster headaches; nasal burning was the most common adverse effect.

Intranasal administration of lidocaine drops (1 mL of a 10% solution placed on a swab in

each nostril for 5 minutes) is possibly helpful; however, it requires a specific and, for
many patients, difficult technique.

Prophylactic agents
Calcium channel blockers may be the most effective agents for CH prophylaxis.[17] They
can be combined with ergotamine or lithium. Of the calcium channel blockers, verapamil
may be the most useful, though others, including nimodipine and diltiazem, have also
been reported to be effective.
Lithium has been suggested as an option because of the cyclical nature of CH, which is
similar to that of bipolar disorders. It effectively prevents CH (particularly in its more
chronic forms)[19] and treats bipolar mood disorder, another cyclic illness. Responses vary
(with chronic CH patients generally being more responsive), but lithium is still a
recommended first-line agent for CH. There is a tendency for the effect to wane after
dramatic relief is seen in the first week.
Methysergide, though no longer available in the United States, is very effective for
episodic and chronic CH prophylaxis. It can often reduce pain frequency, particularly in
younger patients with episodic CH. If it yields no improvement after 3 weeks, it is
unlikely to be beneficial. It should not be given continuously for longer than 6 months; a
drug-free interval of 3-4 weeks must follow each 6-month course.
A few relatively small controlled studies have found anticonvulsants (eg, topiramate and
divalproex) to be effective in the prophylaxis of CH, though the mechanism of action
remains unclear.
Corticosteroids are extremely effective in terminating a CH cycle and in preventing
immediate headache recurrence. High-dose prednisone is prescribed for the first few
days, followed by a gradual taper. Simultaneous use of standard prophylactic agents (eg,
verapamil) is recommended. The mechanism of action in CH is still subject to
speculation.
Tricyclic antidepressants are more helpful as prophylaxis of other headache syndromes.
Beta blockers may worsen bradycardia occurring during the cluster attack.

Nerve Blocks, Ablative Procedures, and Brain Stimulation

Various invasive nerve blocks and ablative neurosurgical procedures (eg, percutaneous
RF ablation, trigeminal gangliorhizolysis, and rhizotomy) have been implemented
successfully in cases of refractory CH.
Percutaneous RF ablation may achieve success in 50% of patients, with fair-to-good
results in 20% and failure in about 30%. Side effects include facial dysesthesia, corneal
sensory loss, and anesthesia dolorosa. Gamma-knife radiosurgery is a less invasive

alternative for pervasive CH but is associated with a significantly increased risk for facial
sensory disturbances.[20] Botulinum toxin injections to manage CH have produced limited
success.[21] Greater occipital nerve block may be beneficial in aborting CH.[10, 22]
Deep brain stimulation with implantation of stimulating electrodes under stereotactic
guidance into the ipsilateral posterior inferior hypothalamus is another potential option
for chronic CH refractory to pharmacologic therapy.[23, 24, 25, 26] This technique is invasive
and is associated with significant risk of complications, including intracranial
hemorrhage.[27] Other serious side effects are subcutaneous infection, micturition syncope,
and transient loss of consciousness.[28]
Stimulation of the sphenopalatine ganglion, which is located in the pterygopalatine fossa,
may also be considered.[29] This approach has shown effectiveness in select patients with
chronic CH.[30]

Prevention
The patient should avoid known headache triggers to the extent possible. For example,
disturbances in the sleep cycle can induce attacks. Strong emotions and excessive
physical activity may also induce attacks.
Tobacco may slow responsiveness to medications. Narcotics may expedite transformation
of episodic CH to chronic CH.

Medication Summary
Pharmacologic management of cluster headache (CH) may be divided into
abortive/symptomatic and preventive/prophylactic strategies. Abortive agents are used to
stop or reduce the severity of an acute attack, whereas prophylactic agents are used to
reduce the frequency and intensity of individual headache exacerbations.
Inhalation of high-flow concentrated oxygen is extremely effective for aborting CH
attacks, though the precise mechanism of action is poorly understood. Oxygen is an
effective alternative to ergotamine. Despite the immediate availability of oxygen in the
emergency department, its widespread use in outpatient setting is impractical.

Neurologics, Other
Class Summary
Triptans may reduce the inflammation associated with migraine headaches.
View full drug information

Zolmitriptan (Zomig, Zomig-ZMT, Zomig Nasal Spray)

As a selective agonist of 5-hydroxytryptamine-1 (5-HT1) receptors in cranial arteries,

zolmitriptan causes vasoconstriction and reduces the inflammation associated with
antidromic neuronal transmission in CH. It can reduce the severity of headache within 15
minutes of subcutaneous injection. The intranasal form is now available in the United
States, offering an attractive alternative to self-injection.
View full drug information

Naratriptan (Amerge)
As a selective agonist of 5-HT1 receptors in cranial arteries, naratriptan causes
vasoconstriction and reduces the inflammation associated with antidromic neuronal
transmission in CH. It can reduce the severity of headache within 15 minutes of
subcutaneous injection.
View full drug information

Sumatriptan succinate (Imitrex, Alsuma, Sumavel DosePro)

As a selective agonist of 5-HT1 receptors in cranial arteries, sumatriptan causes
vasoconstriction and reduces the inflammation associated with antidromic neuronal
transmission in CH. It can reduce the severity of headache within 15 minutes of
subcutaneous injection. The intranasal form is now available in the United States,
offering an attractive alternative to self-injection.

View full drug informationDosing & Uses

AdultPediatricGeriatric

Dosing Forms & Strengths

Migraine Headache
Tablet

25 mg, 50 mg, or 100 mg PO with fluid

Not to exceed 100 mg/dose; additional doses q2hr PRN
Recommended Maximum Dose: 200 mg/day
See also combo with naproxen

Injection

6 mg (0.5 mL) SC with Autoinjector; may Repeat in 1 hour

Not to exceed 12 mg SC/24 hours

Dose may be reduced under certain circumstances, eg, adverse reactions (use only
vials for <6 mg SC dose)

Nasal Spray

5-20 mg, May Repeat in 2 hours

Not to exceed 40 mg/day
Safety not established for >4 headaches/30 day

Renal Impairment
Dose adjustment not necessary

Hepatic Impairment
Oral: Not to exceed 50 mg/dose

Other Indications & Uses

Cluster headache (parenteral)

Rizatriptan (Maxalt, Maxalt-MLT)

Rizatriptan is a selective agonist for 5-HT1 receptors in cranial arteries and suppresses
the inflammation associated with migraine headaches.
View full drug information

Almotriptan (Axert)
Almotriptan is a selective 5-HT1B/1D receptor agonist used to treat acute migraine. It
results in cranial vessel constriction, inhibition of neuropeptide release, and reduced pain
transmission in trigeminal pathways.
View full drug information

Frovatriptan (Frova)
Frovatriptan is used to treat acute migraine. It is a selective 5-HT1B/1D receptor agonist
with a long half-life (24 hours) and a low headache recurrence rate within 24 hours after

taking the drug. It results in cranial vessel constriction, inhibition of neuropeptide release,
and reduced pain transmission in trigeminal pathways. It has unique characteristics and
benefits in the acute treatment of migraine.
View full drug information

Eletriptan (Relpax)
Eletriptan is a selective serotonin agonist that specifically acts at 5-HT1B/1D/1F receptors on
intracranial blood vessels and sensory nerve endings to relieve pain associated with acute
headaches.

Ergot Derivatives
Class Summary
Ergot alkaloids are highly effective in relieving acute CH pain. They are direct
vasoconstrictors of smooth muscle in cranial blood vessels, and their activity depends on
central nervous system (CNS) vascular tone at the time of administration.
View full drug information

Dihydroergotamine (D.H.E. 45 injection, Migranal)

Dihydroergotamine has alpha-adrenergic antagonist and serotonin antagonist effects. It is
available in IV or intranasal preparations and tends to cause less arterial vasoconstriction
than ergotamine tartrate.
View full drug information

Ergotamine (Ergomar)
Ergotamine has alpha-adrenergic antagonist and serotonin antagonist effects and causes
constriction of peripheral and cranial blood vessels. Oral administration of ergotamine is
not as effective as inhaled, rectal, or sublingual administration for treatment of acute
cluster attacks. To prevent rebound headaches, avoid exceeding maximum dosage
guidelines.

Anesthetics, Topical
Class Summary
Local anesthetics stabilize the neuronal membrane so that the neuron is less permeable to
ions. This prevents initiation and transmission of nerve impulses, thereby producing local
anesthesia.
View full drug information

Lidocaine 4%, (Xylocaine)

Lidocaine blocks conduction of nerve impulses by decreasing the neuronal membrane's
permeability to sodium ions, which results in inhibition of depolarization and blockade of
conduction. Intranasal administration of lidocaine drops is an experimental abortive
therapy for CH.

Analgesics, Topical
Class Summary
The short-lived and unpredictable character of CH precludes the effective use of oral
narcotics or analgesics. Despite their lack of efficacy, these substances are abused by
some CH sufferers.
Narcotics are not recommended in aborting cluster headaches.
View full drug information

Capsaicin (Capzasin-P)
Intranasal capsaicin has been successfully tested in clinical trials. This substance, derived
from chili peppers, induces release of substance P, the principal chemomediator of pain
impulses from the periphery to the CNS. After repeated applications, capsaicin depletes
the neuron of substance P and prevents reaccumulation.

Calcium Channel Blockers

Class Summary
These agents inhibit the initial vasoconstrictive phase of CH.
View full drug information

Verapamil (Calan, Verelan, Verelan PM, Covera-SR)

Perhaps the most effective calcium channel blocker for CH prophylaxis, verapamil
inhibits calcium ions from entering slow channels, select voltage-sensitive areas, or
vascular smooth muscle, thereby producing vasodilation. It can be combined with
ergotamine or lithium.

Psychiatry Agents, Other

Class Summary
Lithiums mechanism of action in CH is unclear, though preliminary evidence suggests
that it may interfere with substance P and vasoactive intestinal peptide (VIP)-induced
arterial relaxation.
View full drug information

Lithium carbonate (Lithobid)

Variable responses notwithstanding, lithium is still a recommended first-line agent in CH.
The narrow therapeutic window necessitates close monitoring of levels and adverse
effects. A plasma lithium level of 0.6-1.2 mEq/L measured at steady state 12 hours after
the last dose (ie, just before the next dose) is usually sought, but optimal plasma levels for
prevention of CH are not established. It is thought to be effective against CH at serum
concentrations lower than those required in bipolar disorder (0.3-0.8 mEq/L).

Anticonvulsants
Class Summary
The mechanism of action by which anticonvulsants prevent CH is unclear; it may involve
regulation of central sensitization.
View full drug information

Divalproex sodium (Depakote, Depakote ER)

Few adequate studies of divalproex are available, and results have been mixed.
View full drug information

Topiramate (Topamax)
Topiramate has been effective for prophylaxis of CH in several small prospective studies.
Its exact mechanism of action in this setting is unknown.

Corticosteroids
Class Summary
Corticosteroids are effective for CH that does not respond to lithium. They are intended
for intermittent use during acute flareups. High doses of corticosteroids can ease pain
within 8-12 hours, achieving maximum effectiveness in 2-3 days.
View full drug information

Prednisone
Prednisone is very effective for aborting the CH cycle or providing intermediate
prophylaxis (bridging therapy between acute and prophylactic agents). It is effective for
treatment of CH that does not respond to lithium. Its effects in CH may occur via
inhibition of prostaglandin synthesis. Long-term use is not recommended.
View full drug information

Prednisolone (Millipred, Orapred, Orapred ODT, Prelone)

Corticosteroids act as potent inhibitors of inflammation. They may cause profound and
varied metabolic effects, particularly in relation to salt, water, and glucose tolerance, in
addition to their modification of the immune response of the body. Alternative
corticosteroids may be used in equivalent dosage.

Antiemetics and Sedatives

Class Summary
Antiemetics and sedatives are used to treat CH and emesis associated with acute attacks.
View full drug information

Prochlorperazine (Compro)

Prochlorperazine is an antidopaminergic drug that blocks postsynaptic mesolimbic

dopamine receptors, has an anticholinergic effect, and can depress the reticular activating
system, thereby possibly relieving nausea and vomiting.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Class Summary
Nonsteroidal anti-inflammatory drugs (NSAIDs) may alleviate headache pain by
inhibiting prostaglandin synthesis, reducing serotonin release, and blocking platelet
aggregation. Although their effective in the treatment of headache pain tends to be
patient-specific, ibuprofen is usually the drug of choice for initial therapy. Other options
include naproxen, ketoprofen, flurbiprofen, indomethacin, and ketorolac.
View full drug information

Ibuprofen (Motrin, Advil, Addaprin, Caldolor)

Ibuprofen is the drug of choice for mild to moderate pain. It inhibits inflammatory
reactions and pain by decreasing prostaglandin synthesis. Many doses are available,
either with or without a prescription.
View full drug information

Ketoprofen
Ketoprofen is used for the relief of mild to moderate pain and inflammation. Small doses
are indicated initially in patients with small body size, elderly patients, and persons with
renal or liver disease. Doses of over 75 mg do not increase therapeutic effects. Administer
high doses with caution, and closely observe the patient for response.
View full drug information

Naproxen (Anaprox, Naprelan, Aleve, Naprosyn)

Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions
and pain by decreasing the activity of cyclooxygenase, which is responsible for
prostaglandin synthesis.
View full drug information

Flurbiprofen

Flurbiprofen may inhibit cyclooxygenase, thereby inhibiting prostaglandin biosynthesis.

These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
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Indomethacin (Indocin)
Indomethacin is absorbed rapidly; it is metabolized in the liver via demethylation,
deacetylation, and glucuronide conjugation. It is useful in the diagnosis of CH because it
helps other headache syndromes (eg, chronic paroxysmal hemicrania).
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Ketorolac
Ketorolac inhibits prostaglandin synthesis by decreasing the activity of cyclooxygenase,
thereby resulting in decreased formation of prostaglandin precursors.
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Ketorolac nasal solution (Sprix)

Ketorolac inhibits cyclooxygenase, an early component of the arachidonic acid cascade,
resulting in reduced synthesis of prostaglandins, thromboxanes, and prostacyclin. It has
anti-inflammatory, analgesic, and antipyretic effects and is indicated for short-term ( 5
days) management of moderate to moderately severe pain. The bioavailability of a 31.5mg intranasal dose (2 sprays) is approximately 60% of that of a 30-mg IM dose. The
intranasal preparation delivers 15.75 mg per 100-L spray; each 1.7-g bottle contains 8
sprays.