Headache Help (26 page)

QUICK REFERENCE GUIDE: TREATING CLUSTER HEADACHES

FIRST-LINE MEDICATIONS

1. S
   UMATRIPTAN
   (I
   MITREX
   ) I
   NJECTION OR
   N
   ASAL
   S
   PRAY
        Injections are fast and highly effective.
   
2. OXYGEN
         Easy and inexpensive, inhalations work for 60 percent of cases.
   
3. E
   RGOTAMINE
   T
   ARTRATE
         Suppositories most effective, but medication often triggers side effects, especially anxiety and nausea.
   
4. DHE I
   NJECTIONS
         Effective but doesn’t come in prepackaged auto-injectors.
   

SECOND-LINE MEDICATIONS

1. P
   AIN
   R
   ELIEVERS
   —A
   NTI-INFLAMMATORIES AND
   N
   ARCOTICS
         Trial and error at this point; narcotics can be addicting.
   
2. L
   IDOCAINE
   N
   ASAL
   S
   PRAY
         Useful in combination with other medications
   
3. K
   ETOROLAC
   (T
   ORADOL
   ) I
   NJECTIONS
         Can be effective and fast; a nonsedating, nonaddictive anti-inflammatory.
   
4. A
   NTINAUSEA
   M
   EDICATIONS
         In addition to easing nausea, can promote sedation.
   

FIRST-LINE MEDICATIONS FOR ABORTING CLUSTER HEADACHES

When you first go to a doctor about cluster headaches, chances are that he will recommend one of these treatments to relieve the pain after the headache has started.

1. S
UMATRIPTAN
(I
MITREX
)
INJECTION OR NASAL SPRAY

Imitrex is even more effective for cluster headaches than for migraine headaches. After an injection, the pain may stop in as little as three to five minutes. The nasal spray is milder and may take twenty to thirty minutes to work. The nasal spray should be used on the opposite side of the headache (since your nose will probably be stuffed up on the same side).

The tablets are usually too slow to act; however, if you get prolonged cluster headaches (longer than one hour), you may prefer them. Long-term side effects of daily triptans (such as Imitrex) are not yet known. The other triptans (Amerge, Maxalt, Zomig, Relpax) take longer to work than the Imitrex injections and nasal spray, but may be helpful for prolonged cluster headaches. (See Chapter 5 for more details.)

2.
OXYGEN

This treatment involves inhaling oxygen from a tank. It is very effective in 60 percent of cases, and renting a tank and mask is relatively easy and moderately inexpensive.

To use the oxygen tank, sit, leaning slightly forward. Inhale 100 percent oxygen (8 liters per minute) with the mask, for fifteen to twenty minutes, longer if needed, but no more than one hour a day, assuming you have no pulmonary problems. Oxygen may be used at the same time as Imitrex or ergotamine.

3. E
RGOTAMINE
T
ARTRATE

A moderately effective blood vessel constrictor^ ergotamine tartrate has many side effects, especially severe anxiety and nausea. Although this medication presents the risk of rebound headaches when used with migraines, they do not occur with cluster headaches.

Unlike sumatriptan and DHE, in which the most effective form is an injection, ergotamine tartrate can be effective in pill form, though suppositories are most effective. After age forty, this medication must be used with caution because of the risk for heart complications.

(For details about specific medications in this group, see Chapter 5.)

4. D
IHYDROERGOTAMINE
(DHE)

Similar to sumatriptan, DHE is somewhat less effective but lasts longer and has been on the market for years. Unlike sumatriptan, it is not available in premeasured auto-injectors or in pill form, though it is available in a nasal spray (Migranal Nasal Spray). Injections, however, are the most effective form.

If you have any kind of heart disease, DHE must be used with caution. (For more details, see Chapter 5.)

SECOND-LINE MEDICATIONS FOR ABORTING CLUSTER HEADACHES

When the first-line medications don’t work, there are other options.

1. P
AIN
R
ELIEVERS

At this stage of headache management, the doctor may suggest anything ranging from over-the-counter Excedrin Extra-Strength and Excedrin Migraine to naproxen (Aleve, Anaprox DS), butalbital compounds (Fiorinal or Esgic), or perhaps narcotics, all of which we discuss in detail in Chapter 5. These may be combined with oxygen, Imitrex, or ergotamines. Because addiction is always a potential problem with narcotics, you should resort to them only when the milder options don’t work. (See Chapter 5 for a discussion of addiction versus dependence.)

2. L
IDOCAINE
N
ASAL
S
PRAY

Though rarely useful by itself for treating clusters, lidocaine spray may be recommended in combination with other methods. It is mildly effective but safe, easy to use, and has minimal side effects. Lidocaine may be useful while waiting for the abortives to work.

TYPICAL DOSE
: The pharmacist will put 4 percent lidocaine (from a bottle) into a plastic nasal spray container. Lie down, with your head extended back, and turn your head toward the side of the pain. Spray two or three times but no more than eight in twenty-four hours. If a spray bottle is unavailable, 1 ml of 4 percent lidocaine can be dropped with an eye dropper into the nostril near the pain.

SIDE EFFECTS
: Sometimes temporary numbness in the throat. Nervousness and rapid heartbeat occur rarely.

3. K
ETOROLAC
(T
ORADOL
) I
NJECTIONS

Ketorolac is an effective and fast-acting anti-inflammatory when injected. It is nonsedating and nonaddictive and is available in pill form but must be injected for most effective relief. Prefilled syringes are available, as well as individual vials.

TYPICAL DOSE
: 60 mg in a prefilled syringe or a vial, repeated half an hour or an hour later if needed, with 30 mg or 60 mg. No more than three injections per week.

SIDE EFFECTS
: Use should be monitored and limited during a series of cluster headaches, to avoid kidney and liver complications. Because ketorolac is an anti-inflammatory, it may cause stomach pain.

(See Chapter 5 for more details.)

4. A
NTINAUSEA
M
EDICATION

These medications can help any nausea that occurs, as well as promote sedation, which is sometimes desired to tolerate the cluster.

• P
  ROMETHAZINE
  (P
  HENERGAN
  )
  Promethazine is sedating but has few other side effects. Available in pill or suppository form, promethazine also helps enhance the effectiveness of pain relievers.
  
• P
  ROCHLORPERAZINE
  (C
  OMPAZINE
  )
  AND
  C
  HLORPROMAZINE
  (T
  HORAZINE
  )
  hese are stronger antinausea medications that are useful to promote sedation when you want to avoid going to the emergency room for your pain.
      (See Chapter 5 for more details.)
  

PREVENTING CLUSTER HEADACHES

When abortive medications don’t relieve your cluster headaches and your headaches occur daily for longer than fifteen minutes, most doctors will recommend a preventive. You may choose to take daily preventive medication as soon as a series begins because the headaches are extremely severe and difficult to relieve when in progress. But to take preventive medications, you must be willing to take daily medicine for the length of the cluster series and endure the possible side effects. If you get chronic, rather than intermittent, cluster headaches, you’ll probably do best if you take daily medication year-round or at least while the headaches are severe.

Once you are certain that a cluster cycle has begun, your doctor may recommend that you start taking cortisone, the fastest-acting of the first-line preventive medications, along with another medication in this group, either lithium or verapamil. The theory is that by the time the cortisone is withdrawn (it shouldn’t be taken for too long), the second preventive will have become effective.

When your cluster series ends, the medication can be stopped a week or two after the last headache and not started up again until the first signs of another series. After discovering what’s effective and tolerable for you, your doctor will probably recommend that you institute the same regimen whenever you think a cluster series is beginning, which often occurs at the same time of the year.

QUICK REFERENCE GUIDE: PREVENTING CLUSTER HEADACHES

FIRST-LINE MEDICATIONS

1. C
   ORTISONE
       Very effective but side effects are common: nervousness, moodiness, sleep problems, fatigue, stomach pain.
   
2. V
   ERAPAMIL
       Well-tolerated calcium blocker but takes days to weeks to become fully effective. Can aggravate daily headaches (tension type).
   
3. L
   ITHIUM
       Useful, especially when taken with one of the above, but numerous possible side effects.
   

SECOND-LINE MEDICATIONS

1. M
   ETHYSERGIDE
   (S
   ANSERT
   )
       Sometimes effective but has many side effects.
   
2. V
   ALPROATE
   (D
   EPAKOTE
   )
       Sometimes very useful, but may often cause lethargy and gastrointestinal problems.
   
3. E
   RGOTAMINES
   (C
   AFERGOT
   , B
   ELLERGAL-S
   )
       Not for anyone over forty-five or with high blood pressure, heart disease, or vascular problems.
   
4. E
   RGONOVINE
   (E
   RGOTRATE
   )
       Well tolerated but not as effective as above medications.
   
5. D
   AILY TRIPTANS
       Occasionally effective.
   
6. I
   NDOMETHACIN
   (I
   NDOCIN
   )
       May be just the right thing for some people, but sometimes triggers stomach pain.
   
7. S
   TEROID
   B
   LOCKADE
       Can relieve pain for weeks if other drugs fail; injection is given under the skin at the back of the head.
   

THIRD-LINE MEDICATIONS

1. IV DHE
       Can quickly reduce frequency of headaches while you wait for another preventive medication to kick in.
   
2. C
   OCAINE
   S
   OLUTION
       When nothing else works, during peak problem times.
   

FIRST-LINE MEDICATIONS FOR PREVENTING CLUSTER HEADACHES

As with migraines, the effects of these medications are cumulative, so if one medication is not completely effective, the doctor may recommend a combination of verapamil, lithium, and cortisone. Lithium with verapamil is a common combination for clusters, with or without using cortisone for brief periods.

1. CORTISONE

Prednisone, dexamethasone (Decadron), triamcinolone (Aristocort), or an injectable form (Depo-Medrol).

Cortisone is very effective and used primarily for episodic clusters. Side effects are likely, as your physician and medication package insert will explain. Cluster headache sufferers usually take cortisone for just one or two weeks during the peak of the series.

TYPICAL DOSE
: Should be as small as possible and taken with food. Prednisone, 20 mg (or Decadron, 4 mg) once a day for three days, then 10 mg of prednisone (half a pill) per day for six to ten days. Injectable forms provide quick relief for up to a week, usually not longer. Additional cortisone may be used later in the cycle if the clusters increase.