Mark,

Joe hit the nail square on the head with is comments about doc's not prescribing oxygen therapy for CH'ers because they smoke. 

It is difficult enough to educate physicians on the effectiveness of oxygen therapy as the leading acute treatment and abortive for cluster headache.  However, to have a physician deny use of oxygen therapy to a cluster headache sufferer just because he or she smokes is even more exasperating.

This begs the question as to which is the more unethical action by a physician: 

Refusing to prescribe oxygen therapy for a cluster headache suffer because he or she smokes knowing this method of therapy is the most effective acute treatment and abortive for this disorder,

or

Prescribing oxygen therapy as an abortive to a cluster headache sufferer who smokes?

I did some research...  The VA has an excellent paper on this topic you need to download, read, and take to your neurologist.  It's titled:

Ethical Considerations That Arise When a Home Care Patient on Long Term Oxygen Therapy Continues to Smoke

You can find it at the following link:  Multimedia File Viewing and Clickable Links are available for Registered Members only!!  You need to or

A couple key  passages in this paper jump out at you when you read it:

"The most dangerous situation is smoking while actively using oxygen. A study of burn injuries related to oxygen use found that in 24 of 27 cases, the fire started while the patient was lighting a cigarette (Robb, et al., 2003). Another study showed that 89% of the injuries in these fires were facial burns (Ahrens, 2008). The tendency toward facial burns may be amplified because pure oxygen is heavier than air and so may accumulate in facial hair and upper body clothing.

Overall, however, smokers on LTOT account for only a small fraction of deaths in residential fires. A study of data from Maine, Massachusetts, New Hampshire, and Oklahoma between 2000 and 2007 found a death rate of 3.8 per 10,000,000 population per year from fire incidents related to smoking and LTOT."

[Let's put that death rate in perspective and give it the "So What" test...  There were 3.8 deaths per ten million or 0.038 deaths per 100,000 attributed to smoking associated with the use of oxygen therapy. 

The annual death rate from traffic accidents during that same time frame was 19.1 per 100,000. 

If you do the math, the likelyhood of death from a traffic accident is 19.1/0.038 or 500 times greater than from using oxygen therapy if you're a smoker… but your neurologist didn't tell you not to drive or ride in an automobile.]

Two other interesting passages:

"9.  Denial or withdrawal of LTOT is only justified when the risk to the patient and/or to third parties is so real, substantial, and immediate as to overshadow VHA’s ethical obligation to respect the individual Veteran’s desire to continue this treatment.

10.  VA clinicians and decision-makers who diligently follow the recommendations suggested in this report should not be blamed for bad outcomes that may result from patients smoking in the presence of oxygen."

There are a few things about this document you need to understand that can help place it more clearly in perspective with respect to the use of oxygen therapy as an abortive for cluster headaches.  The first is 98% of all oxygen therapy users are COPD patients who use oxygen therapy at low flow rates with a nasal cannula as a supplement because of low blood oxygenation levels.

Second, unlike cluster headache sufferers who use oxygen therapy to escape excruciating pain, COPD sufferers don't normally experience any pain while they're using supplemental oxygen.  And, as COPD sufferers wear the nose cannula nearly all the time, it's very easy for them to forget it's even there.  That leads to complacency, and for smokers with COPD, that's a recipe for serious trouble if they light a cigarette. 

On the other hand, cluster headache sufferers hold a demand valve, non-rebreathing mask or a mouthpiece with one hand and usually their head with the other hand during oxygen therapy. That makes smoking a very difficult thing to do at the same time as oxygen therapy.

On a related note, if we want to look at relative risk-reward ratios for cluster headache treatments, it's my personal opinion that the long-term use of verapamil as a preventative, and the triptans as abortives, both represent a greater hazard to our health as a cluster headache sufferers than using oxygen therapy.

You'll see what I mean if you take a look at the following link that provides statistics on adverse reactions and side effects attributed to verapamil as reported to the FDA.

Multimedia File Viewing and Clickable Links are available for Registered Members only!!  You need to or

The links relating to death associated with the use of verapamil are sobering:

Index of reports > Cases resulting in death (133).  You'll note that some of these deaths fell into more than one category below:

Completed Suicide (104),  Cardiac Arrest (12),  Drug Toxicity (10),  Poisoning (10),  Cardio-Respiratory Arrest (6),  Intentional Drug Misuse (5),  Poisoning Deliberate (5),  Medication Error (5),  Respiratory Arrest (5),  Intentional Overdose (4)

Try to find similar data on adverse reactions to oxygen therapy...

Let's face it...  smoking is dumb!  There's no rational excuse or reason to smoke... but some of us do even knowing the risks.  Having said that, we don't smoke while pumping gas in our car nor do we smoke while trying to abort a cluster headache with oxygen therapy.  That would be really dumb and a fast way to exit the gene pool.

When it comes to using oxygen therapy as an acute treatment and abortive for cluster headache, it's all a matter of discipline, proper procedures and safety awareness. 

As long as you exercise common sense and follow simple safety procedures, using oxygen therapy to abort cluster headaches is safe.  It's the least expensive acute treatment you can be prescribed as an abortive, and if the flow rate is high enough to support hyperventilation, it can be a very effective abortive with abort times comparable to imitrex injections.

There are two things you need to do when you present your neurologist with the above paper and discuss the relevant facts: 

1. Tell him you are aware of the safety aspects of oxygen therapy and that you are willing to sign a hold-harmless agreement attesting to that.

2. Tell him you have a designated No-Smoking Room, porch, or deck equipped with a fire extinguisher and posted with "No Smoking" and "Oxygen In Use" signs where you can go to use oxygen therapy to abort your cluster headaches and store the oxygen cylinders.

If you do this much, you'll have a better than average chance of receiving the Rx for oxygen therapy from your neurologist. 

Remember, you are your own best advocate when it comes to finding the most effective treatment for you cluster headaches.  Armed with the above information, you have plenty of facts supporting the use of oxygen therapy even if you do smoke.  When you next meet with your neurologist, be polite but firm when you question the logic and rationale behind his decision to refuse you the benefits of oxygen therapy.

Take care and good luck,

V/R, Batch