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.

These therapies aim to terminate an ongoing headache attack.

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.

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.

Preventive treatments aim to reduce the frequency and severity of attacks.

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.

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.

Refractory Chronic Cluster Headache Treatment.

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.

A multidisciplinary approach is essential, involving:

Pain management specialists.
Psychologists (for depression and anxiety related to CCH).
Neurosurgeons and neurologists for advanced interventions.

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.