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Acute cluster headaches are considered to be some of the most severe recurrent pains known for man to suffer. The pain is so severe that some cluster patients have been known to kill themselves because of the attacks. During the acute cluster headache attacks (i.e. the clusters) the patient should avoid wine and medications that contain nitrates.
Oxygen Therapy
Oxygen is the long-standing treatment for an acute cluster attack. Unfortunately, many patients do not respond to this therapy and the opportunity to try oxygen therapy can be somewhat difficult for patients. In general, insurance companies do not want to provide oxygen until they know it will work. Since an individual headache is quite short and commonly at night, it is difficult for patients to get to oxygen fast enough to try it. Dr. Loftus asks his patients to check with their dentist to see if oxygen is available at their office as most patients live closer to their dentist than they do to his office. He will also gives patients a note to hand to the emergency room triage nurse that has an order to give them oxygen in the event the patient is able to get to an emergency room quick enough to receive treatment. If oxygen is effective, it is very useful. It is low cost and essentially side effect free.
Additional Treatments
For patients whom oxygen does not work, Imitrex® injections are usually the treatment of choice since the injections typically work faster than tablets. If the headaches last longer or the patients are “needle-phobic”, then Zomig® or Imitrex® nasal spray is commonly tried. If this is not successful, then any of the fast acting triptan tablets (Axert®, Imitrex®, Maxalt®, Zomig®) can be tried. Unfortunately, many patients have difficulty getting their insurance to pay for their acute triptan use. Injections are commonly used at a very high rate during cluster attacks with evensome patients having multiple attacks per day.
Less commonly used are DHE (dihydroergotamine) injections. These injections are harder to give than Imitrex® because they are not in prefilled syringes and are given either IV or IM (intramuscular). When DHE is given by IV, it requires pre-treatment with an anti-emetic and a saline slush. Some people prefer Imitrex to DHE because Imitrex has fewer side effects. This is particularly true when given in relatively frequent doses which is what is required when treating cluster headache attack as compared to a migraine. Both the triptans and DHE are contraindicated in patients with ischemic heart disease.This makes treating older patients somewhat more complicated than younger patients.
Of course, treating acute attacks should be only part of the initial plan in treating patients with acute cluster headaches. Physicians that do not start the patient on a cluster headache prevention agent are not treating the entire disease.