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Verapamil Cluster Headaches

verapamil cluster headaches

Management of Cluster Headache

Cluster headache, an excruciating, unilateral headache usually accompanied by conjunctival injection and lacrimation, can occur episodically or chronically, and can be difficult to treat. Existing effective treatments may be underused because of underdiagnosis of the syndrome. Oxygen and sumatriptan have been demonstrated to be effective in the acute treatment of cluster headaches. Verapamil has been shown to be effective for prophylaxis. For cluster headache completely refractory to all treatments, surgical modalities and newer interventions such as the implantation of stereotactic electrodes may be useful. Patients should be encouraged to avoid possible triggers such as smoking or alcohol consumption, especially during the cluster period. The intensity of cluster headache pain leads to ethical concerns among researchers over the use of placebo, making randomized controlled trials difficult. As new technology and genetic studies clarify the etiology of cluster headache, it is possible that more specific therapies will emerge.

Cluster Headache

Acute Drug Treatment

The goal of treatment for cluster headache is to decrease the pain, severity, and duration of each attack. Early intervention is critical yet difficult, since a single cluster headache can be as short as 15 minutes. Non-oral routes of administration for medications are therefore preferable.


Oxygen inhalation is the first line therapy for cluster headache. Treatment is initiated with 100% oxygen at max flow rate of 7 to 10 liters per minute. Treatment should continue for 15 minutes. Although up to 70% of patients experience relief within five to ten minutes, some patients report that oxygen suppresses rather than aborts the attack and that pain may return. There are no side effects with this treatment.

Symptoms and Triggers

Cluster headaches are often seasonal. The attacks often awaken people from sleep at the same time each night. Most people experience more than one attack each day, often in the late afternoon or evening. About 10 to 20 percent of patients have chronic cluster headaches that never go away or have remission periods of less than one month.

Cluster headache pain comes on quickly and usually without a warning – an attack can last from 15 minutes to three hours. There might be other vague symptoms prior to an attack, such as mood changes, yawning, or food cravings.

Cluster headaches are excruciating – they are sometimes called “suicide headaches” – and patients often describe the pain as boring, stabbing, knifelike, or burning.

The pain is located around the eyes and temple but can also extend to other areas such as the:

  • Jaw
  • Cheek
  • Teeth
  • Nose
  • Side of the head

In most patients, the attacks occur on the same side of the head during a cluster period.

Most patients experience agitation or become restless during a cluster headache and prefer to pace, rock back and forth, go outdoors, or strike their head to distract themselves from the pain. Others prefer to sit still, but it is uncommon to want to lie down during an attack.

Cluster headaches are often accompanied by involuntary symptoms, often on the same side of the head as the pain. These symptoms are caused by activity of specific nerves in the brain and head. They include:

  • Droopy eyelid
  • Small pupil
  • Eyelid swelling
  • Tearing
  • Bloodshot eye
  • Stuffy or runny nose
  • Flushing
  • Sweating

Some patients with cluster headaches also have symptoms that are more typical of migraine, such as:

  • Aura
  • Sensitivity to light or noise
  • Nausea
  • Vomiting

Most patients with cluster headaches are smokers or ex-smokers. Common triggers for cluster headaches include:

  • Alcohol
  • Odors such as those from solvents or perfume
  • Sleep
  • Smoking
  • Certain foods
  • Diagnosis

To diagnose cluster headaches, UT Southwestern physicians will conduct a thorough evaluation of a patient’s medical history and perform a neurological examination.

Brain imaging is recommended for all patients with cluster headaches. Rarely, brain abnormalities (such as a tumor of the pituitary gland) can cause headaches that are very similar to cluster headaches.

Treatment Options

Cluster headaches can be a lifelong condition in most patients, although remission periods tend to get longer with age. To reduce the severity and the frequency of these headaches, three aspects of treatment are generally all started at the same time.

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