Peter Goadsby's latest CH article (co-authored with Anna S. Cohen). "Prevention and treatment of cluster headache", PROGRESS IN NEUROLOGY AND PSYCHIATRY, 6/2009, 13(3):9-16. (This citation is sufficient to give to your doc or for your library to obtain a copy for you.)

Because the length of the article prevents posting it here, I'm going to pull out a few items which are not common to our knowledge/experience, as often posted here.

This post should not be considered a summary of the article or as a basic primer in the treatment of CH.

1. Disorders of the pituitary can appear to be CH, or related types, and this is why they recommend MRI along with pituitary function tests as part of the initial diagnostic work-up of suspected CH.

2. When history suggests that ECH cycle is short (less than 6-weeks):

     Preventive therapy-short term: GON injection [greater occipital nerve]; Naratriptan 2.5mg, 2x/day or electriptan 40mg, 2x/day.

3. ECH with history of longer cycles (greater than 6-weeks):

     Preventive therapy-short term: GON injection

     CCH, also GON injection.

4. Preventive therapy-longer term.

     Methysergide, with usual warnings, for all.
     Re. Topiramate, Gabapentin-note of absence of controlled studies of effectiveness but might consider if all else fails.
     Melatonin for short cycle ECH and CCH (although no controlled studies with CCH).

5. Sumatriptan, 6mg dosing. "At this dosage, there was no tachyphylaxis even in long-term use."

6. Sumatriptan, current limit to 2 injections/3 nasal a day. Comment that a 4mg dose may allow more frequent use (although no recommendation given)-IF no cardiovascular risk factors or personal or family history of migraine (in order to avoid the triptan overuse syndrome).

7. Verapamil, ref. recent recognition of possible ECG/heart abnormalities: A recent study showed this incidence to be about 20%--giving us some guidance about how much concern is useful.

Thanks so much for posting this very usefull information.

Bob,

I'm clearly confused...  Is this a teachable moment?  Dónde está la oxygen therapy as the first abortive of choice recommended by the expert task force appointed by the Scientific Committee of the European Federation of Neurological Societies (EFNS) as shown below?

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The above represents a peer-reviewed statement of minimum desirable standards for the guidance of practice based on the best available evidence.  In short, oxygen therapy was listed at the top of the list in the standards of treatment for acute cluster headaches...  Authored I might add by none other than Dr. Peter Goadsby, MD, pHd...  See the following sources...

BIBLIOGRAPHIC SOURCE(S)

   * May A, Leone M, Afra J, Linde M, Sandor PS, Evers S, Goadsby PJ, EFNS Task Force. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol 2006 Oct;13(10):1066-77.

Did the good Dr. Goadsby have an epiphany on a better treatment of the cluster headache disorder or is he just following the gold suggesting more lucrative procedures and treatments that will enable neurologists treating cluster headache sufferers to justify charging more for their time?  

I realize that in the EU under social medicine, the cost of the procedure should not be a factor as long as it is effective so this makes no sense except here in the US where medical insurance companies pay physicians based on the Healthcare Common Procedure Coding System (HCPCS) coding system.

Again, I can't access the complete article so I'm a bit confused here... Was oxygen therapy mentioned at all in the full article?

Take care,

V/R, Batch

Quote:

Because the length of the article prevents posting it here, I'm going to pull out a few items which are not common to our knowledge/experience, as often posted here.

My take on this is that Bob was just pulling out a few things that may not be common knowledge. I would be very surprised if Goadsby didn't mention 02 as being the gold standard.

O2 is in the article.   ;)  It's listed as an abortive 9-12LPM for 15 min at the start of attack as req to be used in addition to having triptans as abortives.  

It is listed after triptans as the "other" first choice abortive though.   :-?   Says no side effects, and all the good stuff about it - can be used several times daily, etc...   Baffling why it would be 2nd in the article and in the chart.  It was there though.

Val

Val,

Thanks for the clarification...  As one of the leading experts on our disorder, Dr. Goadsby is one gent we need to listen to on advances in treatments.  I'm glad to hear that oxygen therapy is still part of his suggested regimen of treatment. Having spoken with him in Dallas on the role of oxygen therapy as an abortive in treating our disorder, the consistent theme was use it first and use it early to be effective...

Thanks again.

V/R, Batch

The full article is here at this link (at least it works for me, for now??):
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Note in the article that the recommended abortive therapy is triptans AND oxygen (not OR).  That can be lost in a quick read.

As it is a great review article, as it uses quotes/data from recent studies, an update was needed.

However, IMO as a review paper there are no disclosures about funding sources or "conflicting interests", which MAY explain the apparent preferential billing given to the triptans over oxygen.

Regardless, it is a great paper, a good one to pass on to unknowing GP's and such.

Doug