Treatment and Therapy of Cluster Headache

        Medical Treatment and Therapy of the cluster headache can be divided into the treatment of acute attacks, and preventive medicine, which aims to suppress the attack. Acute and preventive treatment started simultaneously when the initial period of the cluster. Latest surgical treatment options and neuro stimulation has replaced detrimental treatment approaches.

A. Treatment of Acute Attacks
Cluster headache attacks are usually short, from 30 to 180 minutes, often become heavy quickly, thus requiring a rapid initial treatment. The use of excessive drug headaches are common in patients with cluster headache, usually when they've had a history of migraines or have a family history of migraine, and when the treatment given is not very effective in acute attacks, such as oral triptans, analgesic acetaminophen and the opiate receptor agonists.

• Oxygen: Oxygen inhalation, levels of 100% as much as 10-12 liters / min for 15 minutes is very effective, and is a safe treatment for acute cluster headache.
• Triptans: Sumatriptan 6 mg subcutaneous, intranasal sumatriptan 20 mg and zolmitriptan 5 mg intranasal effective in the acute treatment of cluster headache. Three doses of zolmitriptan within twenty-four hours could be acceptable. There is no evidence to support the use of oral triptans in cluster headache.
• dihydroergotamine 1 mg intramuscularly effective in relieving acute attacks of cluster headache. How intranasal look less effective, although some patients the beneficial use manner.
• Lidocaine: lidocaine topical nasal drops can be used to treat acute attacks of cluster headache. Patients sleep on his back with his head tilted back 30 ° to the direction of the floor and move to the side of headache. Nasal drops can be used and the dose of 1 ml lidocaine 4% which can be repeated after 15 minutes.

B. Preventive Medicine
Treatment options in the prevention of cluster headache is determined by the duration of the attack, not by the type of episodic or chronic. Preventive considered short term or long term, based on how fast and how long the effect can be used safely. Many experts now propose verapamil as a first-line treatment option, although in some patients with short attack only need oral corticosteroids or occipital nerve injection may be more appropriate.

• Verapamil is more effective than placebo and better than lithium. Clinical practice clearly supports the use of doses of verapamil were relatively higher in cluster headache, certainly higher than the dose used for cardiology indications. After examination ECG, patients begin a dose of 80 mg three times a day, the daily dose will be gradually increased from 80 mg every 10-14 days. ECG examination conducted every increase dose and at least ten days after a dose change. Dose increased until the cluster attacks disappeared, side effects or maximum dose of 960 mg per day. Side effects include constipation and swelling of the legs and gingival hyperplasia (patients should continue to monitor the cleanliness of teeth).
• Corticosteroids in the form of prednisone 1 mg / kg to 60 mg for four days for three weeks lowered gradually accepted as a short-term preventive treatment approach . This treatment often stop the cluster period , and can be used no more than once a year to avoid aseptic necrosis .
• Lithium carbonate is primarily used for chronic cluster headache as a side effect, although it can be used in various episodes . Normally lithium dose of 600 to 900 mg per day in divided doses . Lithium levels should be checked in the first week and periodically thereafter with a target serum levels of 0.4 to 0.8 mEq / L. Neurotoxic effects including tremors , letargis , slurred speech , blurred vision , confusion , nystagmus , ataxia , extrapyramidal signs , and seizures . Coadministration with diuretics that reduce sodium should be avoided , as it can lead to increased lithium levels and neurotoxic . Long-term effects such as hypothyroidism and renal complications should be monitored in patients taking lithium for long periods of time . Increased polymorphonuclear leukocytes are the reactions that occur due to the use of lithium and often one will sense the presence of occult infection . The use along with indomethacin may increase levels of lithium .
• Topiramate is used to prevent cluster headache attacks . Dose is 100-200 mg per day , with the same side effects as its use in migraine .
• Melatonin may help cluster headache as preventive and one controlled study showed better than placebo . Commonly used dose is 9 mg per day .
• Other preventive drugs include gabapentin ( up to 3600 per day ) and methysergide ( 3 to 12 mg per day ) . Methysergide not available easily , and should not be used on an ongoing basis in order to avoid complications in the treatment of fibrosis . Divalproex is not effective for the treatment of cluster headache .
• Injection of the occipital nerve : Injection of methylprednisolone ( 80 mg ) with lidocaine into the area around the occipital nerve ipsilateral to the location of the largest attack resulted in improvement for 5 to 73 days . This approach is very helpful in the short attack and to reduce the overall pain and prolonged attack on chronic cluster headache .
• Approach Surgery : Modern surgical approach on cluster headache is dominated by deep brain stimulation in the posterior hypothalamus area of ​​the gray matter and occipital nerve stimulation . There is no obvious place for destructive actions , such as thermoregulation trigeminal ganglion or sensory root of the trigeminal nerve .

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