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For further information, see CMDT Part 24-01: Headache
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Affects mainly middle-aged men
May relate to activation of cells in the ipsilateral hypothalamus, triggering the trigeminal autonomic vascular system
There is often no family history of headache or migraine
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Severe unilateral periorbital pain occurring daily for several weeks
Often accompanied by ipsilateral nasal congestion, rhinorrhea, redness of the eye, lacrimation, or Horner syndrome
Episodes often occur at night and last for between 15 minutes and 3 hours
During attacks, patients are often restless and agitated
Precipitants of an attack
Alcohol
Stress
Glare
Specific foods
Spontaneous remission occurs, and the patient remains well for weeks or months before another bout occurs
Bouts may last 4–8 weeks and may occur up to several times per year
Occasionally, remission does not occur; this variant is chronic cluster headache
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Sumatriptan, 6 mg subcutaneously or 20-mg/spray intranasally, or inhalation of 100% oxygen (12–15 L/min for 15 min) may be effective
Dihydroergotamine (0.5–1 mg intramuscularly or intravenously) is sometimes used
Viscous lidocaine (1 mg of 4–6% solution) intranasally is sometimes effective
For prophylaxis, give ergotamine tartrate as rectal suppositories (0.5–1.0 mg at night or twice daily), orally (2 mg once daily), or by subcutaneous injection (0.25 mg three times daily for 5 days per week)
Other potentially helpful prophylactic agents include
Lithium carbonate (start at 300 mg daily, titrating according to serum levels and treatment response up to a typical total daily dosage of 900–1200 mg divided into 3–4 doses per day)
Verapamil (240–960 mg daily orally)
Topiramate (100–400 mg daily orally)
Galcanezumab (300 mg subcutaneously monthly until end of cluster period)
Prednisone (60–100 mg daily for 5 days followed by gradual withdrawal over 7–10 days) is effective in 70–80% of patients
Suboccipital corticosteroid injection about the greater occipital nerve is effective in 75% of patients
Ergotamine tartrate
Hemicrania continua completely resolves with indomethacin
Electrical stimulation
Stimulation of the vagus nerve at headache onset successfully aborts pain in 30–50% of attacks
Twice daily prophylactic stimulation reduces attack number in chronic cluster headache
Approved in the United States
In Europe, sphenopalatine ganglion stimulation is approved for treatment of cluster headache based on efficacy in one randomized sham-controlled study
Stimulation of the occipital nerve reduces headache frequency, but it does not have regulatory approval