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Two Treatment Strategies for CH Î Symptomatic therapy taken at the time of an attack. Î Preventive therapy taken when the cluster bout begins, to prevent further attacks. Acute Treatment of CH Attacks Î Level A advice can be given for the use of subcutaneous sumatriptan 6 mg, intranasal zolmitriptan 5 and 10 mg, and 100% oxygen. Î Level B advice can be given for the use of intranasal sumatriptan 20 mg and oral zolmitriptan 5 and 10 mg. Î Level C advice can be given for intranasal 10% cocaine hydrochloride, intranasal 10% lidocaine, and subcutaneous octreotide 100 mcg. Î There is insufficient evidence to advise the use of dihydroergotamine, ergotamine, somatostatin, and prednisone for the acute treatment of CH (Level U). Prevention of CH Attacks during a Cluster Bout Î Level B advice can be given for intranasal civamide (100 microL of 0.025%) and suboccipital steroid/local anesthetic injection in the region of the greater occipital nerve. Î Sumatriptan and sodium valproate are not advised for the prevention of CH (Level B). Î Level C advice can be given for melatonin 10 mg daily, verapamil 360 mg daily, and lithium 900 mg daily. Î Cimetidine, chlorpheniramine, misoprostol, and 100% hyperbaric oxygen are not advised for the prevention of CH (Level C). Î There is insufficient evidence to advise the use of intranasal capsaicin, nitrate tolerance, and prednisone for the prevention of CH (Level U). Transitional Treatments Certain medications started with longer-term preventive drugs stop the CH attacks almost immediately and maintain pain relief until the dose of the longer-term preventive drug can be increased and becomes effective. Transitional therapies are especially appropriate for patients who present with a high frequency of attacks. Most transitional therapies have not been subjected to rigorous clinical trials but are commonly used in clinical practice. Î Oral steroids (prednisone 60 mg daily for 3 days, then decreased by 10 mg every 3 days for a total of 18 days). Î Dihydroergotamine (1 mg subcutaneous/intramuscular twice a day for several days). Î Ergotamine tartrate 1 or 2 mg given once daily or in divided doses. Î Suboccipital steroid injections. Selecting a Treatment Regimen