Chronic Cluster Headache Treatment [Neurosurgery Wiki]

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====== Chronic Cluster Headache Treatment ======

[[Chronic Cluster Headache]] (CCH) is a persistent and often refractory condition. Its treatment includes **acute abortive therapies**, **preventive (prophylactic) approaches**, and in refractory cases, **surgical or neuromodulatory interventions**.

===== 1. Acute Abortive Treatment =====
These therapies aim to terminate an ongoing headache attack.

==== a. First-Line Options ====
  * **High-Flow Oxygen Therapy:**
    * **Dosage:** 100% oxygen at 12–15 L/min via a non-rebreather mask.
    * **Timing:** Administered for 15–20 minutes.
    * **Effectiveness:** Most effective when started at the onset of an attack.
  * **Subcutaneous Sumatriptan:**
    * **Dosage:** 6 mg subcutaneously.
    * **Effectiveness:** Rapid relief, often within 15 minutes.
    * **Limitations:** Maximum of 2 doses/day due to cardiovascular risks.

==== b. Second-Line Options ====
  * **Intranasal Zolmitriptan or Sumatriptan:**
    * Alternative for patients intolerant to subcutaneous injections.
  * **Intranasal Lidocaine:**
    * **Dosage:** 4% lidocaine solution instilled into the ipsilateral nostril.
  * **Other Options:**
    * **Dihydroergotamine (DHE):** Administered intramuscularly or intravenously during severe clusters.

===== 2. Preventive (Prophylactic) Therapy =====
Preventive treatments aim to reduce the frequency and severity of attacks.

==== a. First-Line Preventive Medications ====
  * **Verapamil:**
    * **Dosage:** 240–960 mg/day (titrated gradually).
    * **Monitoring:** Regular ECG checks to avoid heart block.
  * **Corticosteroids (Short-Term Bridge Therapy):**
    * **Dosage:** Prednisone 40–60 mg/day, tapered over 2–3 weeks.
    * **Use:** Used to break a cycle while long-term preventives take effect.

==== b. Second-Line Preventive Medications ====
  * **Lithium Carbonate:**
    * **Dosage:** 600–1200 mg/day.
    * **Monitoring:** Regular serum level and renal function tests.
  * **Topiramate:**
    * **Dosage:** 50–200 mg/day.
  * **Galcanezumab:**
    * A monoclonal antibody targeting CGRP, approved for cluster headaches.

===== 3. Refractory Chronic Cluster Headache =====

[[Refractory Chronic Cluster Headache Treatment]].


===== 4. Lifestyle Modifications =====
  * **Avoid Known Triggers:** Alcohol, tobacco, strong smells, stress, and irregular sleep patterns.
  * **Maintain a Regular Sleep Schedule:** Circadian disruptions can worsen attacks.
  * **Cluster Headache Diaries:** Helpful for tracking attack patterns and identifying triggers.

===== 5. Multidisciplinary Management =====
A **multidisciplinary approach** is essential, involving:
  * Pain management specialists.
  * Psychologists (for depression and anxiety related to CCH).
  * Neurosurgeons and neurologists for advanced interventions.

===== 6. Emerging Therapies =====
  * **CGRP Monoclonal Antibodies:** Investigational for CCH.
  * **Non-invasive Neuromodulation:** Vagus nerve stimulators are being studied.

**Conclusion:** Chronic Cluster Headache requires tailored acute, preventive, and advanced therapies. Early recognition of refractory cases is crucial for exploring surgical or neuromodulatory options.