New Guideline Assesses the Evidence Base for Treatment of Cluster Headache

The American Headache Society (AHS) has released a new guideline for the treatment of cluster headache. According to the authors, the AHS guideline can be used for understanding which therapies are superior to placebo or sham treatment in the management of cluster headache. “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,” said lead author Matthew S. Robbins, MD, an Associate Professor of Clinical Neurology at Montefiore Headache Center at Albert Einstein College of Medicine in the Bronx, New York, and his coauthors. The guideline was published in the July/August issue of Headache.

Matthew S. Robbins, MD

The guideline is based on a systematic review of the literature regarding abortive and preventive treatment of cluster headache, and represents an update of the American Academy of Neurology’s 2010 recommendations. “The interval of time that has elapsed since completion of the 2010 literature review necessitates these updated recommendations,” the authors said.

For the current literature review, the authors searched the Medline, PubMed, and EMBASE databases for double-blind, randomized, controlled trials that investigated treatment of cluster headache in adults.

For acute treatment, sumatriptan subcutaneous, zolmitriptan nasal spray, and high-flow oxygen remain the treatments with a Level A recommendation. A study of sphenopalatine ganglion stimulation conducted after the 2010 review was added to the current guideline with a Level B recommendation.

The previous guideline included no Level A recommendation for prophylactic therapy. For the current guideline, suboccipital steroid injections have emerged as the only treatment to receive a Level A recommendation, due to the publication of a second Class I study in the literature. Other newly evaluated treatments since the 2010 guideline include a negative study of deep brain stimulation (Level B), a positive study of warfarin (Level C), and negative studies of cimetidine/chlorpheniramine (Level C), and a negative study of candesartan (Level C). Frovatriptan received a Level U recommendation.

The authors concluded that “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.”

—Glenn S. Williams