Medications
Medications used to treat cluster headache are grouped into 3 main areas:
Preventive medication - these are medications you may use on a daily basis to try to prevent your CH from occurring. Finding the right medications that are suitable, tolerable and effective for you can take some time, and the problem is that usually, you need to take such medications for a month before they start to work, and of course by then you cluster may be on it's way out anyway.
Abortive medication - these are medications that you use when you begin to feel your cluster headache attack begin, taken only on a "per-attack" basis. When taken at the beginning of a CH attack may stop a cluster headache before it reaches full intensity
Transitional Medication - Steroidal anti-inflammatory medications, usually containing Cortisone (Prenisone, Prednisolone, Dexamethasone etc) are often used as an acute intervention measure. Occasionally a local anesthetic called Lidocaine/Lignocaine infusion may be used as an acute transitional therapy, administered intravenously to inpatients in hospital.
You may find that you need to take a combination of medications to effectively manage your cluster headaches. Medication that may work quite well for one patient, may fail in another. What works for you in this cluster headache period may not work for you the next time you have another bout of cluster attacks.
Preventatives
- Calcium channel blockers.
The calcium channel blocking agent verapamil (Calan, Verelan, others) is often the first choice for preventing cluster headache. Verapamil may be used with other medications. Occasionally, longer term use is needed to manage chronic cluster headache.
Side effects may include constipation, nausea, fatigue, swelling of the ankles and low blood pressure.
VERAPAMIL (Calcium channel blocker)
"Verapamil is a calcium antagonist used in the treatment of high blood pressure and heart disease. It is the first line treatment for the suppression of cluster headache attacks. However, the maximum licensed dose for heart disease is 480 mg daily. Verapamil does not penetrate the brain very well and experience from cluster experts is that the dose may need to go considerably higher up to double the recommended maximum dose or even higher again with a maximum of 1200 mg daily. Clearly such use is "off-label, and going beyond the maximum recommended dose should only be done under specialist supervision.
The particular concern is that verapamil causes a slowing of communication between the pacemaker part of the heart and the main pumping chambers. We can easily measure this on the ECG. If the effect is too much it could cause a loss of communication between the pacemaker part of the heart and the pumping chambers resulting in a very slow heart rate. This is not a heart attack or cardiac arrest but would not be desirable. In practice this means we (practitioners) generally fairly quickly get patients up to 480 mg daily using a controlled-release formulation. Further increases are only done after an assessment of the patient and a review of the ECG. Practitioners should only conclude that verapamil has failed once you have got to either the maximum dose listed above, the ECG suggests we should not go higher or the patient otherwise has unacceptable side-effects. However, verapamil is generally very well tolerated with usually the only symptom of concern being constipation."
Click here for access to "Verapamil" Consumer Medical Information (CMI) sheets, from the Australian Pharmaceutical Benefits Scheme (PBS) A-Z Medicine listing. - NERVE BLOCK
Injecting a numbing agent (anesthetic) and corticosteroid into the area around the occipital nerve, situated at the back of your head, might improve chronic cluster headaches.
An occipital nerve block may be useful for temporary relief until long-term preventive medications take effect. It's often used in combination with verapamil. - CORTICOSTEROIDS
Inflammation-suppressing drugs called corticosteroids, such as prednisone (Prednisone Intensol, Rayos), are fast-acting preventive medications that may be effective for many people with cluster headaches.
Your doctor may prescribe corticosteroids if your cluster headache condition has started recently or if you have a pattern of brief cluster periods and long remissions.
Although corticosteroids might be a good option to use for several days, serious side effects such as diabetes, hypertension and cataracts make them inappropriate for long-term use.
PREDNISOLONE (Cortisone) - STEROID
"Most patients can get temporary control of the episode of cluster headache using high-dose prednisolone." Professor Paul Rolan notes, of Cortisone in relation to cluster headache treatment, that in his experience as a headache specialist and pain clinician; "In any individual patient there is particular dose which completely controls the symptoms and even a small reduction below that leads to complete loss of control. In other words, it seems to be an "all-or-none" effect. Unfortunately doses that need to be used are often very high between 25 and 75 mg daily. These are not safe for long-term use and can cause major long-term problems but for a week or two are probably not too much of a problem. The main concern is brain stimulation and excitation with sleeplessness. There can be serious weight gain with these drugs. Their best use is as a very short-term stopgap whilst getting other treatments on board."
Click here for access to "Prednisolone" Consumer medical Information (CMI) sheets, from the PBS A-Z Medicine listing. - LITHIUM
Lithium carbonate. Lithium carbonate (Lithobid), which is used to treat bipolar disorder, may be effective in preventing chronic cluster headache if other medications haven't prevented cluster headaches.
Side effects include tremor, increased thirst and diarrhea. Your doctor can adjust the dosage to minimize side effects.
While you're taking this medication, your blood will be checked regularly for the development of more-serious side effects, such as kidney damage.
"Lithium is normally only used for the prevention of attack of flare-ups of manic depression. There is some evidence that it is effective in cluster. It has a narrow safety margin which means that dosage is adjusted according to blood levels. It can cause a number of side effects on mood and concentration and with prolonged use can be damaging to the kidneys.
Click here for access to "Lithium" Consumer medical Information (CMI) sheets, from the Pharmaceutical Benefits Scheme (PBS) A-Z Medicine listing. - Anticonvulsant medications
Usually used in treatment of Epilepsy, also sometimes in the treatment of Migraine headache and Neuropathic pain syndromes, such as; Divalproex Sodium (Depakote), Sodium Valproate (valproic acid), Gabapentin (Neurotonin), Lyrica (Pregalbin), Lamotrigine (Lamictal), Levetiracetam (Keppra), Topiramate (Topamax), may be tried as preventive medications in Cluster Headache if other treatments are not well tolerated, or deemed ineffective.
Click here for the Pharmaceutical Benefits Scheme A-Z Medicine listing, where you can search alphabetically for information (CMI sheets) on any of your medications.
Abortives
- Imigran® (Sumatriptan) is universally reported by many CH patients as the most effective abortive drug, with around 96% of sufferers finding the injectable form completely effective in aborting a CH attack.
Sumatriptan is available under many different brand names and now also comes in generic forms, with many Pharmacies now stocking "in-house" brands.
Imigran is taken as an injection, nasal spray, tablet, or Fast Dispersion Tablet (FDT).
Injections can be expensive, so many CH patients choose the cheaper and more widely available option of tablets or nasal sprays.
The injectable form, which is self-administered under the skin (subcutaneously) using an auto-injector kit, will begin to work in 5 minutes or shortly after, often bringing about complete relief in under 15 minutes.
The Nasal Spray usually aborts the attack after 15 minutes from administering
NOTE: You should ask your GP for a 'Private script' for the nasal spray, because:
- you can get 7 boxes (14 doses) at a time,
- It is around $11 CHEAPER than the medicare price.
For example:
The medicare price for a box of 2 sprays is about $28.
The non medicare price is about $18 (even less at Chemist warehouse, at $16.50 per box).
Nasal spray tips:
- You will spray into nthe nostril on the side that you get the CH
- Blow your nose gently to remove mucus from your nasal passages.
- Tilt your head slightly forward and close the nostil on the side that your DOPN't get your CH by gently pressing against the side of your nose with your finger.
- Insert the tip of the nasal spray into the other nostril. Point the tip toward the back and outer side of your nose. Make sure to direct the spray straight back, not up into the tip of your nose.
- Squeeze the nasal spray bottle as you begin to slowly breathe in through your nose.
- Sniff gently as you spray the medication, as if smelling your favorite food or a flower. Don't snort the spray, which can cause the medication to go into your throat.
- Remove the tip of the nasal spray from your nostril and breathe out through your mouth
How it works:
Sumatriptan is structurally similar to serotonin (5HT), and is a 5-HT receptor (types 5-HT1D and 5-HT1B) agonist. (An 'Agonist is a substance which initiates a physiological response when combined with a receptor.)
The specific receptor subtypes it activates are present on the cranial arteries and veins. Acting as an agonist at these receptors, sumatriptan reduces the vascular inflammation associated with migraines.
The specific receptor subtype it activates is present in the cranial and basilar arteries. Activation of these receptors causes vasoconstriction of those dilated arteries. Sumatriptan is also shown to decrease the activity of the trigeminal nerve, which, it is presumed, accounts for sumatriptan's efficacy in treating cluster headaches. The injectable form of the drug has been shown to abort a cluster headache within fifteen minutes in 96% of cases.
Further reading:
Click here for the NPS Medicinewise list of allowable substitute Sumatriptan tablets that appear on the Pharmaceutical Benefits Scheme.
Also available on the PBS Medicine listing - Imigran ® (Sumatriptan) Consumer Medical Information (CMI) sheets from the manufacturer, GSK:
Imigran Fast Dispersion Tablet (FDT) Consumer Medical Information (CMI)
Imigran Injection MK2 Consumer Medical Information (CMI)
Imigran Tablets Consumer medical Information (CMI)
Imigran Tablets, Injection, Nasal Spray Product Information (PI)
- Oxygen
Oxygen therapy may help people with CH, but it does not help prevent future episodes. Typically it is given via a non-rebreather mask at 15 liters per minute for 15-20 minutes. Around 70% improve within 15 minutes.
Oxygen treatment of headaches was first mentioned in literature in 1939. Mr. Charles E. Rhein, Linde Air Products Co., reported to Dr. Alvarez at the Mayo Clinic in Rochester, MN the successful treatment of severe "migraine” attacks by breathing pure oxygen. Subsequently, Dr. Alvarez noted that the treatment with 100 percent oxygen at a flow of six to eight liters a minute would often produce relief. Sometimes patients would not be able to obtain relief with this treatment, whereas at other times they would. In 1940, Dr. Alvarez reported the treatment of over 100 persons suffering from headache attacks. They were treated with oxygen with a nasal type of mask and a flow of six to eight liters a minute. He found that 80 percent of "migrainous” headaches were completely or significantly relieved. Dr. Alvarez also found that patients with other types of headaches were often helped through the use of oxygen inhalation and that the prompt institution of therapy had a better chance of resulting in relief than if it was delayed. This work was much less rigorous than that done recently.
The first significant work done on oxygen inhalation was that of Dr. Kudrow who investigated patients with cluster headaches. Fifty-two out-patients were treated with 100 percent oxygen at a flow of seven liters per minute. 75 percent of these patients had "complete or almost complete cessation of head pain within 15 minutes: for at least seven of 10 attacks.” Dr. Kudrow found that there is greater effect of oxygen inhalation in patients with episodic cluster. Patients younger than 50 years of age appeared to have a better response than those above age 50. However, this was not considered statistically significant. Also of interest was that 62 percent of those responding to oxygen had their attacks relieved within seven minutes of starting therapy. Dr. Kudrow did a second trial in a crossover fashion, comparing sublingual ergotamine tartrate and oxygen inhalation in the abortive treatment of cluster headache. Fifty patients selected at random used either 100 percent oxygen or the ergotamine to treat their headaches. After 10 cluster headaches were treated with one modality the patient then used the other treatment for 10 headaches. Eighty-two percent of the subjects found at least seven out of 10 cluster headaches were successfully relieved by the oxygen, while 70 percent treated their headaches successfully with ergotamine. These results were not considered statistically different.
Dr. Fogan studied 19 patients with cluster headache in the most rigorous fashion possible through a double-blind crossover study comparing oxygen versus air inhalation. He found there was a significant difference in the relief obtained in those patients inhaling oxygen versus air. By making this comparison Dr. Fogan was able to be sure that the oxygen was the significant factor in successfully treating the cluster headaches. He eliminated the other associated factors involved with the inhalation of a gas, such as the gas tank and the oxygen mask.
The way in which oxygen inhalation reduces headache pain is unknown. Researchers have shown that there is an increased blood flow in the brain in both cluster and migraine headaches, although both headaches do not have the same degree of increased flow. It has been shown that oxygen causes a marked decrease in cerebral blood flow that is coincident with the reduced degree of pain in cluster headache.
While it is clear that oxygen is a very useful therapy in cluster headaches, its utility in migraine headaches is less well documented. It is unlikely that the literature of the 1930s and 1940s was able to distinguish between migraine and cluster headaches. Thus, any belief ascribed to migraine headaches in that era could have confused patients with cluster headaches with those of migraine headaches. Some investigators have found it useful, however, to use oxygen therapy in patients with migraine headaches. I have found approximately 50 percent of my patients with migraine headaches will be able to achieve some relief with oxygen therapy. They use 100 percent oxygen for eight to nine liters a minute for up to 30 minutes. If no effect has been achieved by that time, it is unlikely that one will occur.|
The side effects of oxygen inhalation are rare. Cluster headache patients are very often smokers and if one should happen to light up while an oxygen tank is open, the result can be explosive. Another side effect of oxygen use was found by Dr. Kudrow who noticed that 25 percent of his study patients had rebound cluster headaches after oxygen inhalation therapy. No other side effects have been found and therefore, oxygen therapy is safe. Oxygen could be preferred to ergotamine’s use since ergotamine often causes nausea and vomiting as well as a sense of unreality and leg cramps. Ergotamine cannot be used in patients with hypertension, peripheral vascular disease or infections when oxygen obviously can be. It has been suggested that oxygen therapy when used together with ergotamine will give greater relief than the sum of the effect found by using either one alone.
Oxygen therapy is not a well-known modality for headache patients. Many physicians are unaware of the benefits of oxygen therapy, as are third-party payers who hesitate to reimburse for its use. Sometimes this can be overcome by a letter from the treating physician. Since approximately 50 percent of patients respond to oxygen therapy, it is worth trying it before going to the expense and effort of having an oxygen tank installed in one’s home.
By George H. Sands, M.D.
Beth Israel Medical Center
New York, New York
Some tips for your visit to the GP, specialist and Pharmacy:
Visiting your GP.
Go to your GP well prepared - and also make sure that they are well prepared. Print off as much information as you can from the sources on this site and take it with you to your GP or specialist appointment if you can. Make sure that you have also read the information you have found and have a general idea as to what your options are.
GP's and nursing staff in Accident & Emergency rooms are not trained to know everything about cluster headache so try not to blame them for lack of knowledge. Cluster headache is relatively rare and is most definitely a specialist area. Be polite but persistent with your GP, many GPs will sometimes not prescribe the correct medication on any number of grounds. If they suffered the same pain that you do they would prescribe what you needed in a heartbeat! Sometimes, if you feel like you are getting nowhere, you may have to seek a second opinion and find an alternative GP.
A trip to a Specialist may be required.
GPs may not know all the specialty areas in treating CH, nor should they as they are not Neurology specialists. Your GP may need to refer you to a Neurology specialist for further assessment, correct diagnosis, treatment and access to some medications.
The Australian Pharmaceutical Benefits Scheme (PBS) currently lists no medications approved for specific use in cluster headache. GPs themselves can only prescribe a few medications suitable for use in cluster headache and although they will do their best to help, they can have a hard time working within the constraints of our health system.
In some chronic and intractable cluster headache cases, specialist referral will certainly be required to obtain medications for "off-label", or "experimental use", or for use at higher than normal dosages. These medications are usually well understood and are routinely used in treating cluster headache.
Some medications fall within the specific area of Specialist or Neurologist care for treatment of cluster headache. A Specialist, or Neurologist can make arrangements to have medications effective in cluster headache prescribed for you. There may be a waiting list to see a Specialist or Neurologist.
Sometimes a GP will refer you to a Pain Management Unit (PMU), where a dedicated multi-disciplinary team of medical Specialists can work with you to find solutions to your Cluster Headache condition. Sometimes a PMU approach may help you avoid the need for medications in the first place, or even help to reduce your reliance on medications you may already use. A specialist PMU team can help arrange medication and many other treatment approaches appropriate for you where you may have other medical conditions, or medications to consider. Wait lists for PMU clinics can be at times, quite long, but access to this type of care can be well worth the wait.
Headache Diary
There is something you can do while you are working with your GP and waiting to see your Specialist or Pain Management Unit team; fill in your Headache Diary. For those new to cluster headache, or for those with existing headache conditions looking to clarify or review their diagnosis, printing off a headache diary and keeping records of your headaches is generally a good idea.
The only way a practitioner can correctly diagnose headache conditions is through taking a detailed oral patient history from you. What you tell them will form the basis of your diagnosis and access to the correct medication. Gathering as much data as you can on your headache condition is very helpful to all involved. A Headache diary also allows you to list any medication(s) or treatments you may already be using and how effective they are for you.
Taking a copy of your headache diary to your GP or Specialist will save both them and yourself much time in settling on the correct diagnosis and quickly accessing appropriate medication(s) for you. A Headache Diary can help you and your practitioner to increase your chances of becoming pain free much sooner..
Click here for a link to an excellent Headache Diary from NPS Medicinewise. The introduction explains why a headache diary is necessary for both you and practitioners and has full instructions on how to fill it in.
At the Pharmacy
When you have received your prescriptions, be sure your prescriptions allow you enough medication to avoid running short. If this is a problem ensure you ask for more medication when you need it - most doctors will make arrangements for repeat medication if you simply keep going back and be persistent.
Although sometimes difficult to get, "Regulation 24" Authority prescriptions enable GPs to offer a patient prescribed medications with all repeats dispensed by Pharmacy in one go, so you don't run short. Regulation 24 prescriptions are for people who cannot regularly make it to a Pharmacy, or are going away on holiday. Great for travelers.
Consumer Medical Information (CMI) sheets
When you do get your medication(s), ask your Pharmacist for a print off of your medication's CMI, or "Consumer Medical Information" sheet. Read these sheets carefully and thoroughly to make sure you have not been prescribed a medication that will conflict (a drug interaction) with a different medication that you may be taking.
Many drugs used to treat cluster headache are from the same drug groups. Be careful not to double up on the same drug type. Be sure to check the CMI sheet for a list of other drugs that should not be taken in combination with your newly prescribed medication.
Contraindications
In medicine, a contraindication is a condition or factor that serves as a reason to withhold a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain treatment.
Also check your CMI sheet to see that your medication is not contraindicated; that is when a drug is inappropriate for you to use. This may be because you may be allergic to it, or one of its ingredients, or you may have another medical condition in which your new medication prescribed for cluster headache, is inappropriate for you to take.
Your GP should assess you for any contraindications before prescribing any medication. If you have a known existing medical condition, known allergy, or feel that any medication may be inappropriate for you to use, please ask your GP, Specialist and Pharmacist about it. Asking questions about drug contraindications can save you from some nasty situations and may even save your life.
Be sure to ask your Pharmacist to check your medications at the time of collecting them. Most Pharmacies and GPs now have software that can pick up dangerous drug interactions and contraindications at point of sale, before you are left alone with a sore head to work it out for yourself.
Let your Pharmacist know what medications you already take, so they can assess your new medication for safety. This helps save many patients from an undesirable drug interaction or contraindication and possibly an unscheduled emergency hospital visit.
GPs, Specialists and Pharmacists are trained to pick up on contraindications and known drug interactions. Don't rely solely on the systems of GPs, specialists and Pharmacists to get it right! Mistakes can still happen, so be sure to check for safety and know about your new medication before taking it.
Medications can be a complex and tricky business to get right in Cluster Headache treatment, so don't ever be afraid to ask questions of your GP, specialist, or Pharmacist, no matter how trivial or silly the question may seem. It's what health care professionals are there for; to help you manage your condition, safely, effectively and to keep you well informed of what is going on at all times.
Feel free to post on the forum, ask any questions about medications. Whilst we are not Doctors and cannot provide medical advice; with many years of combined experience as CH patients site users are here to help and can provide names of GPs, practitioners, CMI sheets and if asked, can also offer the benefit of their own personal experiences with Medications they may have used in Cluster Headache.
It is strongly advised that you discuss any or all of this with your GP and/or Specialist and work together to create a good plan on how best to treat your headaches.
All medications mentioned above are medications prescribed by a health care professional. Health care professionals will discuss any medications and pre-existing medical conditions with you. When working with you, Practitioners will assess you for suitability of any medication and assess the risks and benefits of any medication(s) before prescribing any medication to you.
Remember; we are not Doctors, this information is provided for reference and/or information purposes only, as explained in the site disclaimer below. Always discuss any medication or treatments for Cluster headache with a qualified health care professional.