Treatment of Cluster Headache: The American Headache Society Evidence‐Based Guidelines

Abstract

Background.-Cluster headache (CH), the most common trigeminal autonomic cephalalgia, is an extremely debilitating primary headache disorder that is often not optimally treated. New evidence-based treatment guidelines for CH will assist clinicians with identifying and choosing among current treatment options.Objectives.-In this systematic review we appraise the available evidence for the acute and prophylactic treatment of CH, and provide an update of the 2010 American Academy of Neurology (AAN) endorsed systematic review.Methods.-Medline, PubMed, and EMBASE databases were searched for double-blind, randomized controlled trials that investigated treatments of CH in adults. Exclusion and inclusion criteria were identical to those utilized in the 2010 AAN systematic review.Results and Recommendations.-For acute treatment, sumatriptan subcutaneous, zolmitriptan nasal spray, and high flow oxygen remain the treatments with a Level A recommendation. Since the 2010 review, a study of sphenopalatine ganglion stimulation was added to the current guideline and has been administered a Level B recommendation for acute treatment. For prophylactic therapy, previously there were no treatments that were administered a Level A recommendation. For the current guidelines, suboccipital steroid injections have emerged as the only treatment to receive a Level A recommendation with the addition of a second Class I study. Other newly evaluated treatments since the 2010 guidelines have been given a Level B recommendation (negative study: deep brain stimulation), a Level C recommendation (positive study: warfarin; negative studies: cimetidine/chlorpheniramine, candesartan), or a Level U recommendation (frovatriptan).Conclusions.-This AHS guideline can be utilized for understanding which therapies have superiority to placebo or sham treatment in the management of CH. In clinical practice, these recommendations should be considered in concert with other variables including safety, side effects, patient preferences, clinician experience, cost, and the invasiveness of the intervention. Given the lack of Class I evidence and Level A recommendations, particularly for a number of commonly used preventive therapies, further studies are warranted to demonstrate safety and efficacy for established and emerging therapies.

Therapeutical approaches to paroxysmal hemicrania, hemicrania continua and short lasting unilateral neuralgiform headache attacks: a critical appraisal

“…From the available data ONS has emerged as the best technique and this result is in accordance with the findings in CH, were ONS is the only class-A evidence treatment for the American Headache Society (AHS) [193]. Moreover, even the European Headache Federation (EHF) has confirmed the effectiveness and safety of this technique in SUNCT and SUNA, pointing out that 4 patients out of 6 analyzed were nearly pain free with mild facial paresthesia as the principal AE [183].…”

Long-Term Results of Deep Brain Stimulation of the Mamillotegmental Fasciculus in Chronic Cluster Headache

“…Recently, the American Headache Society Guideline classified DBS for CCH as B level negative evidence (possibly ineffective) [20]. On the other hand, we know this is a safe procedure and with a reasonable success rate as reported in several series [3,7,12,21,22].…”

Greater Occipital Nerve Injection versus Oral Steroids for Short Term Prophylaxis of Cluster Headache: A Retrospective Comparative Study

“…The median number of times that transitional treatments were received per patient was 3 (range [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. The median number of times that transitional treatments were received per patient was 3 (range [1][2][3][4][5][6][7][8][9][10][11][12][13][14].…”

“…In the current AHS guidelines, GON injections are the only therapy that has class A evidence for prophylactic treatment of CH attacks, 9 which was based on 2 randomized controlled trials. In the current AHS guidelines, GON injections are the only therapy that has class A evidence for prophylactic treatment of CH attacks, 9 which was based on 2 randomized controlled trials.…”