Selecting a Treatment Regimen
Two Treatment Strategies for CH ÎSymptomatic therapy taken at the time of an attack.
ÎPreventive therapy taken when the cluster bout begins, to prevent further attacks.
Acute Treatment of CH Attacks
ÎLevel A advice can be given for the use of subcutaneous sumatriptan 6 mg, intranasal zolmitriptan 5 and 10 mg, and 100% oxygen.
ÎLevel B advice can be given for the use of intranasal sumatriptan 20 mg and oral zolmitriptan 5 and 10 mg.
ÎLevel C advice can be given for intranasal 10% cocaine hydrochloride, intranasal 10% lidocaine, and subcutaneous octreotide 100 mcg.
ÎThere 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
ÎLevel 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.
ÎSumatriptan and sodium valproate are not advised for the prevention of CH (Level B).
ÎLevel C advice can be given for melatonin 10 mg daily, verapamil 360 mg daily, and lithium 900 mg daily.
ÎCimetidine, chlorpheniramine, misoprostol, and 100% hyperbaric oxygen are not advised for the prevention of CH (Level C).
ÎThere 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.
ÎOral steroids (prednisone 60 mg daily for 3 days, then decreased by 10 mg every 3 days for a total of 18 days).
ÎDihydroergotamine (1 mg subcutaneous/intramuscular twice a day for several days).
ÎErgotamine tartrate 1 or 2 mg given once daily or in divided doses. ÎSuboccipital steroid injections.
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