RISK FACTORS: Male gender, Age > 30 years, Small amounts of vasodilators, such as, alcohol or nitroglycerin, Occasional relationship to previous head trauma or surgery
GENERAL MEASURES
o During cluster periods, avoid alcohol, bright lights and glare, excessive emotion and stress as these may
precipitate attacks o Avoid narcotic analgesics, especially oral preparations
o Tobacco (high predilection for tobacco abuse in this population) may make patients more refractory to
therapy
SURGICAL MEASURES Radiofrequency trigeminal gangliolysis in carefully selected refractory patients with strictly unilateral attacks
ACTIVITY
o Avoid self-injury during bouts of excruciating pain
o Vigorous physical activity at first symptom may abort attack in some
o Compression of ipsilateral carotid or temporal artery may reduce pain in some. Caution exercised in recommending carotid massage in patient at risk for occult carotid disease.
DIET
o During cluster phase, alcohol even in small amounts frequently precipitates attacks
o Rarely, specific foods may trigger attacks
PATIENT EDUCATION
o Focus on the validity, natural history, and pathology of the condition
o Advise patient to avoid known precipitants
o Assist patient with learning self-treatment methods
o Provide supportive relationship and follow-up
o Avoid high altitudes
DRUG(S) OF CHOICE
o General information
? Prophylactic therapy is paramount
? Avoid pain therapy for acute attacks, especially narcotic analgesics
? Assess cardiovascular risk before instituting vasoactive drugs, such as, ergotamine or sumatriptan
o Acute attacks
? Oxygen 100% at 7-10 liters for 10-15 minutes administered through a tight-fitting face mask with patient
in sitting position and breathing at normal respiratory rate
? Sumatriptan (Imitrex) 6 mg subcutaneous, maximum of 12 mg per 24 hours with at least 1 hour between
injections
? Dihydroergotamine mesylate (DHE 45) 1 mg IM or IV. May teach self-administration with SC.
o Prophylaxis (to shorten cluster period or prevent expected attacks):
? Verapamil up to 80 mg PO qid spaced evenly through waking hours
? Lithium carbonate (Eskalith) 300 mg 2-4 times a day
? Ergotamine timed to be at peak serum level during anticipated attack, e.g., 2 mg rectal or 1-2 mg oral
2 hours before. This is especially useful to prevent nocturnal attacks.
? Prednisone, various schedules, e.g., 60-80 mg PO for 7 days followed by rapid tapering over 6 days or
40 mg/day for 5 days tapered over 3 weeks. This therapy is initiated while other long-term agent is being employed, such as, verapamil or lithium.
ALTERNATIVE DRUGS
o Acute attack:
? Lidocaine intranasal instillation of 1 mL of 4% topical solution slowly on same side as symptoms. Position
patient supine with head extended 45 degrees and rotated 40 degrees to the side of pain. May need to premedicate with 1-2 drops of intranasal 0.5% phenylephrine for nasal stuffiness.
o Prophylaxis
? Indomethacin up to 150 mg per day in divided doses. Absolute responsiveness in chronic paroxysmal
hemicrania (CPH) and useful in female cluster patients.
? Nifedipine 40-120 mg/day
? Nimodipine up to 240 mg/day
? Combinations of verapamil and lithium with or without ergotamine may be useful when single drug therapy is ineffective
? Histamine desensitization done at certain major headache centers
PATIENT MONITORING
o To anticipate cluster bouts and initiate early prophylaxis
o Monitor for adverse medication response and side-effects
o Monitor for unmasking of underlying cardiovascular disorder
o Education for patient and family
PREVENTION/AVOIDANCE
o Alcohol, nitroglycerine, and some foods can induce cluster attack
o Disturbances in sleep cycle can induce attacks (sleep cycle disruption common due to anticipation and occurrence of nocturnal attacks)
o Strong emotions, anger, excessive physical activity may induce attacks
o Tobacco may slow responsiveness to medication
o Narcotics may expedite transformation of episodic cluster to chronic cluster
POSSIBLE COMPLICATIONS
o Self-injury during attack
o Side-effects of medication including unmasking of coronary heart disease
o Potential for drug abuse
o High flow oxygen may be problematic in patients with COPD or who smoke
EXPECTED COURSE/PROGNOSIS
o Recurrent attacks
o Prolonged remissions
o Possibility of transformation of episodic cluster to chronic cluster and occasionally chronic cluster to episodic cluster