Cluster Headache Features and Therapeutic Options

A review article titled “Cluster Headache: Clinical Features and Therapeutic Options” written by Charly Gaul, Hans-Christoph Diener, and Oliver M. Muller published in Deutsches Ärzteblatt International (vol. 108, issue 33, pages 543-549, 2011) provides an interesting look on new options for those with a chronic refractory cluster headache.

The article discusses how 120,000 people in Germany are affected by cluster headache. The attacks are in the periorbital area on one side and last 90 minutes on average. The attacks often posses a circadian and seasonal rhythm. The author lists the diagnostic criteria for cluster headache as from the International Classification of Headache Disorders (ICHD-II).

First line drugs for treatment include verapamil and cortisione or lithium and topirmate. In addition, short term relief can be obtained by local anesthetics and steroids along the course of the greater occipital nerve.

I have taken verapamil as discussed over at and also had lidocaine injected into my occipital nerve as discussed over at as treatment strategies after suffering from a 24/7 headache 2 days after having all 4 healthy wisdom teeth removed. I did not have a positive experience with the occipital nerve block which just led to more lasting pain and problems.

Another treatment strategy is inhaling oxygen which I also have experience with. The author also suggests administering lidocaine solution into the nostril which I also have experience with as well.

In those cluster headaches that are refractory to treatment which is defined as a cluster headache that over 24 months has significant impairment’s to the patient’s quality of life and socioeconomic status there is no uniform treatment strategy. Guidelines recommend verapmil of greater than 400 mg, lithium carbonate of greater than 800 mg, topiramate of greater than 100 mg, indomethacin of greater than 150 mg to exclude hemicrania continua, methysergide of greater than 8 mg, and corticosteroids such as prednisolone of greater than 100 mg.

I also did take indomethacin and prednisolone in the earlier stages of my treatment.

The author goes on to discuss newer invasive procedures that are available for severely impacted patients with chronic cluster headaches that are refractory to treatment which includes deep brain stimulation in the hypothalamus (DBS) and bilateral occipital nerve stimulation (ONS).

The author states

“Ablative procedures such as rhizotomy of the root exit zone of the trigeminal nerve or destructive procedures to the Gasserion ganglion have been abandoned because of severe irreversible side effects (anesthesia dolorosa). Stereotactic radiosurgical interventions (gamma knife) have proved effective in a small case series, albeit at the cost of persistent hyposensitization.”

Other possibilities mentioned include spinal cord stimulation (SCS), vagus nerve stimulation (VNS), and stimulation of the sphenopalatine ganglion (SPG) but limited evidence is available for these methods.

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