Background & Aims
Management of cluster headache, known for severe unilateral periorbital pain in circadian attacks(1), has gained advancements in drug treatments over the past years, particularly for the episodic form.(2) However, managing chronic cluster headaches presents a growing challenge, with conventional options proving limited effect. Since the 2009 review(3), a substantial body of evidence has emerged, specifically focusing on the treatment of medically intractable chronic cluster headaches (MICCH) (4). This review seeks to comprehensively examine both pharmaceutical and non-pharmaceutical alternatives, with emphasis on managing medically intractable cluster headaches with neuromodulation.
Methods
This narrative review builds upon the previous paper by Van Kleef et al., published in 2009.(3) Our latest literature update was performed in December 2023. Furthermore, we searched the reference sections of all reviewed articles to identify any missing publications.
Results
Oxygen(5,6) therapy and subcutaneous sumatriptan(7,8) offer immediate relief for acute cluster headache attacks. Verapamil(2) and lithium(9,10) are effective prophylactic therapies, though they require close monitoring due to potential side effects. When other options fail, topiramate(11) with gradual dosage titration is considered. Corticosteroids(12) serve as rapid and effective transitional therapy. Non-invasive Vagus Nerve Stimulation(13) is recommended for well-tolerated and effective abortive treatment in episodic cluster headaches. In chronic cases like MICCH, invasive neuromodulation like Sphenopalatine Ganglion Stimulation(14) have proven effective for abortive therapy, while Occipital Nerve Stimulation(15) is recommended for prophylactic therapy. Deep Brain Stimulation(16), though promising, has limited use due to the risk of intracranial hemorrhage. Each treatment option carries specific considerations and contraindications, emphasizing the importance of personalized care.
Conclusions
In conclusion, recent advancements in cluster headache treatment, particularly in neuromodulation, have significantly improved patient care. Management strategies are dependent on a combination of pharmaceutical, non-invasive and invasive treatments to abort acute attacks and prevent new attacks from happening. When the cluster headache becomes chronic and medically intractable the trend shifts towards prophylactic invasive treatment. Careful patient selection, monitoring, and awareness of potential complications guide the choice of therapies.
References
1.Olesen J. International Classification of Headache Disorders. Lancet Neurol. 2018;17(5):396-7
2.Diener HC, May A. Drug Treatment of Cluster Headache. Drugs. 2022 Jan;82(1):33-42. doi: 10.1007/s40265-021-01658-z.
3.van Kleef M, Lataster A, Narouze S, Mekhail N, Geurts JW, van Zundert J. Evidence-based interventional pain medicine according to clinical diagnoses. 2. Cluster headache. Pain Pract. 2009;9(6):435-42.
4.Membrilla JA, Roa J, Díaz-de-Terán J. Preventive treatment of refractory chronic cluster headache: systematic review and meta-analysis. J Neurol. 2023 Feb;270(2):689-710. doi: 10.1007/s00415-022-11436-w.
5.Kudrow L. Response of cluster headache attacks to oxygen inhalation. Headache. 1981;21(1):1-4.
6.Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA. 2009;302(22):2451-7.
7.Sumatriptan Cluster Headache Study G. Treatment of acute cluster headache with sumatriptan. N Engl J Med. 1991;325(5):322-6.
8.Ekbom K, Monstad I, Prusinski A, Cole JA, Pilgrim AJ, Noronha D. Subcutaneous sumatriptan in the acute treatment of cluster headache: a dose comparison study. The Sumatriptan Cluster Headache Study Group. Acta Neurol Scand. 1993;88(1):63-9.
9.Bussone G, Leone M, Peccarisi C, Micieli G, Granella F, Magri M, et al. Double blind comparison of lithium and verapamil in cluster headache prophylaxis. Headache. 1990;30(7):411-7.
10.Lund NLT, Petersen AS, Fronczek R, Tfelt-Hansen J, Belin AC, Meisingset T, et al. Current treatment options for cluster headache: limitations and the unmet need for better and specific treatments-a consensus article. J Headache Pain. 2023;24(1):121.
11.Lainez MJ, Pascual J, Pascual AM, Santonja JM, Ponz A, Salvador A. Topiramate in the prophylactic treatment of cluster headache. Headache. 2003;43(7):784-9.
12.Ornello R, Lambru G, Caponnetto V, Frattale I, Di Felice C, Pistoia F, et al. Efficacy and safety of greater occipital nerve block for the treatment of cluster headache: a systematic review and meta-analysis. Expert Rev Neurother. 2020;20(11):1157-67.
13.de Coo IF, Marin JC, Silberstein SD, Friedman DI, Gaul C, McClure CK, et al. Differential efficacy of non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: A meta-analysis. Cephalalgia. 2019;39(8):967-77.
14.Schoenen J, Jensen RH, Lanteri-Minet M, Lainez MJ, Gaul C, Goodman AM, et al. Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham-controlled study. Cephalalgia. 2013;33(10):816-30.
15.Wilbrink LA, de Coo IF, Doesborg PGG, Mulleners WM, Teernstra OPM, Bartels EC, et al. Safety and efficacy of occipital nerve stimulation for attack prevention in medically intractable chronic cluster headache (ICON): a randomised, double-blind, multicentre, phase 3, electrical dose-controlled trial. Lancet Neurol. 2021;20(7):515-25.
16.Franzini A, Ferroli P, Leone M, Broggi G. Stimulation of the posterior hypothalamus for treatment of chronic intractable cluster headaches: first reported series. Neurosurgery. 2003;52(5):1095-9; discussion 9-101.
Presenting Author
Casper Lansbergen
Poster Authors
Topics
- Evidence, Clinical Trials, Systematic Review, Guidelines, and Implementation Science