Conflict of Interest: None.
The Usual Treatment of Trigeminal Autonomic Cephalalgias
Article first published online: 1 OCT 2013
© 2013 American Headache Society
Headache: The Journal of Head and Face Pain
Volume 53, Issue 9, pages 1401–1414, October 2013
How to Cite
Pareja, J. A. and Álvarez, M. (2013), The Usual Treatment of Trigeminal Autonomic Cephalalgias. Headache: The Journal of Head and Face Pain, 53: 1401–1414. doi: 10.1111/head.12193
- Issue published online: 1 OCT 2013
- Article first published online: 1 OCT 2013
- Manuscript Accepted: 26 JUN 2013
- trigeminal autonomic cephalalgia;
- cluster headache;
- paroxysmal hemicrania;
Trigeminal autonomic cephalalgias include cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection, tearing, and rhinorrhea (SUNCT). Conventional pharmacological therapy can be successful in the majority of trigeminal autonomic cephalalgias patients.
Most cluster headache attacks respond to 100% oxygen inhalation, or 6 mg subcutaneous sumatriptan. Nasal spray of sumatriptan (20 mg) or zolmitriptan (5 mg) are recommended as second choice. The bouts can be brought under control by a short course of corticosteroids (oral prednisone: 60-100 mg/day, or intravenous methylprednisolone: 250-500 mg/day, for 5 days, followed by tapering off the dosage), or by long-term prophylaxis with verapamil (at least 240 mg/day). Alternative long-term preventive medications include lithium carbonate (800-1600 mg/day), methylergonovine (0.4-1.2 mg/day), and topiramate (100-200 mg/day).
As a rule, paroxysmal hemicrania responds to preventive treatment with indomethacin (75-150 mg/day).
A short course of intravenous lidocaine (1-4 mg/kg/hour) can reduce the flow of attacks during exacerbations of SUNCT. Lamotrigine (100-300 mg/day) is the preventive drug of choice for SUNCT. Gabapentin (800-2700 mg/day), topiramate (50-300 mg/day), and carbamazepine (200-1600 mg/day) may be of help.