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Bob_Johnson
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Treatment guidelines from Europe
« on: Jul 30th, 2007, 7:59am » |
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EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias.
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. [143 references]
MAJOR RECOMMENDATIONS
The levels of evidence (class I-IV) supporting the recommendations and ratings of recommendations (A-C, good practice point) are defined at the end of the "Major Recommendations" field.
Table 5. Treatment Recommendations for Cluster Headache, Paroxysmal Hemicrania and Short-lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection and Tearing (SUNCT) Syndrome
Treatment of Choice
Therapy Cluster Headache Paroxysmal Hemicrania SUNCT Syndrome
Acute 100% oxygen, 15 l/min (A)
Sumatriptan 6 mg, subcutaneous (A)
Sumatriptan 20 mg nasal (A)
Zolmitriptan 5 mg nasal (A/B)
Zolmitriptan 10 mg nasal (A/B)
Zolmitriptan 10 mg oral (B)
Zolmitriptan 5 mg oral (B)
Lidocaine intranasal (B)
Octreotide (B) None None
Preventative Verapamil (A)
Steroids (A)
Lithium carbonate (B)
Methysergide (B)
Topiramate (B)
Ergotamine tartrate (B)
Valproic acid (C)
Melatonin (C)
Baclofen (C) Indomethacin (A)
Verapamil (C)
Non-steroidal anti-inflammatory drugs (NSAIDs) (C) Lamotrigine (C)
For exact doses see original guideline document (A denotes effective, B denotes probably effective, C denotes possibly effective).
Treatment of Cluster Headache
Level A Recommendation
The first option for the treatment of acute attacks of cluster headache should be the inhalation of 100% oxygen with at least 7 l/min over 15 min (class II trials) or with the subcutaneous injection of 6 mg sumatriptan (class I trials). An alternative would be sumatriptan 20 mg nasal spray or zolmitriptan 5 mg nasal spray (one class I trial each), with the disadvantage of a slower onset and the advantage of being able to treat more attacks in 24 hours than with injected sumatriptan.
Prophylaxis of cluster headache should be tried first with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy or tolerability, electrocardiogram [ECG] controls are obligatory with increasing doses). Although no class I or II trials are available, steroids are clearly effective for treating cluster headache. Therefore, the use of at least 100 mg methylprednisone (or equivalent corticosteroid) given orally or up to 500 mg intravenously (i.v.) per day over 5 days (then tapering down) is recommended.
Level B Recommendation
Intranasal lidocaine (4%) and subcutaneous octreotide (100 micrograms) can be tried for treating acute cluster headache attacks if level A medication is ineffective or contraindicated. Oral administration of zolmitriptan at 5 to 10 mg is effective in some patients (class I trial) but high doses produce more side effects and limit practical use.
Methysergide and lithium are drugs of second choice if verapamil is ineffective or contraindicated. Corticosteroids can be used for short periods where bouts are short or to help establish another medication. Topiramate is promising, but only open trials exist at this point. Melatonin is useful in some patients. Except for lithium, the maximum dose depends on efficacy and tolerability. Ergotamine tartrate is recommended for short-term prophylaxis (class III studies). Despite positive class II studies, pizotifen and intranasal capsaicin should only be used in rare cases because of side effects.
Level C Recommendation
Baclofen 15 to 30 mg and valproic acid showed possible efficacy and can be tried as drugs of third choice.
Good Practice Point
Surgical procedures are not indicated in most of the patients with cluster headache. Patients with intractable chronic cluster headache should be referred to centres with expertise in both destructive and neuromodulatory procedures to be offered all reasonable alternatives before a definitive procedure is conducted.
Treatment of Paroxysmal Hemicrania
Paroxysmal hemicrania is to be treated with indomethacin up to 200 mg (level A recommendation). Alternatively, verapamil and other NSAIDs can be tried (level C recommendation).
Treatment of Short-lasting Unilateral Neuralgiform Headache Attacks with Conjunctival Injection and Tearing (SUNCT) Syndrome
Recent large case series outcomes suggest that lamotrigine is the treatment of choice in SUNCT, followed by topiramate and gabapentin.
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Bob Johnson
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birdman
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Re: Treatment guidelines from Europe
« Reply #1 on: Jul 30th, 2007, 8:08am » |
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Thanks for the info. Always very informative stuff.
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cluster
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Re: Treatment guidelines from Europe
« Reply #2 on: Sep 12th, 2007, 5:45pm » |
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A. May, M. Leone, J. Áfra, M. Linde, P. S. Sándor, S. Evers, P. J. Goadsby:
EFNS guidelines on the treatment of cluster headache and other
trigeminalautonomic cephalalgias.
European Journal of Neurology. 2006; 13: 1066–1077.
Download free full text:
http://www.efns.org/files/guideline_49.pdf
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sandie99
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Re: Treatment guidelines from Europe
« Reply #3 on: Sep 13th, 2007, 2:38am » |
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The brand new clusterheadaches leaflet back here in Finland recommends O2, but just 7-10 lpm.
I don't recall reading anyone reminding Finnish clusterheads about the importance of the right kind of mask, either.
I'm going to check and see what the Finnish O2 users do and what their experiences are.
Sanna
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DennisM1045
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Re: Treatment guidelines from Europe
« Reply #4 on: Sep 13th, 2007, 6:20am » |
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Great stuff Bob. Thanks for highlighting and distilling this info. Birdman, thanks for the link. I'll be bringing this to my Neuro next week.
-Dennis-
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michael
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Re: Treatment guidelines from Europe
« Reply #5 on: Sep 13th, 2007, 11:31am » |
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Excellent info - thanks!
Mike
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totka2
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Re: Treatment guidelines from Europe
« Reply #6 on: Sep 14th, 2007, 4:02am » |
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on Sep 12th, 2007, 5:45pm, cluster wrote:
A. May, M. Leone, J. Áfra, M. Linde, P. S. Sándor, S. Evers, P. J. Goadsby:
EFNS guidelines on the treatment of cluster headache and other
trigeminalautonomic cephalalgias.
European Journal of Neurology. 2006; 13: 1066–1077.
Download free full text:
http://www.efns.org/files/guideline_49.pdf
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Hello Friedrich cluster,
Thanks for the link. Although Dr. Judit Áfra works hard for the EFNS (abroad) we can't get "legal" oxygen in Hungary because of our FNHIF (Fucking National Health Insurance Fund)
Steve
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Beastfodder
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Re: Treatment guidelines from Europe
« Reply #7 on: Sep 17th, 2007, 8:15am » |
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Hope this helps GPs get it right more often.
Suspect it'll still be down to militant minded individuals bringing the information to GPs so they can find more effective prescription remedies.
Million miles from the rubbish I was prescribed with initially !
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O2 and clusterbusters - naturally
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cluster
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Re: Treatment guidelines from Europe
« Reply #8 on: Sep 17th, 2007, 9:42am » |
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on Sep 14th, 2007, 4:02am, totka2 wrote:
Hello Friedrich cluster,
Thanks for the link. Although Dr. Judit Áfra works hard for the EFNS (abroad) we can't get "legal" oxygen in Hungary because of our FNHIF (Fucking National Health Insurance Fund)
Steve |
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Hello Steve,
I feel sorry that you have no access to "legal" O2 and think this a part of your civil rights to receive adequate medical treatment.
Have you tried to apply here: http://www.obh.hu/allam/eng/index.htm ?
pf wishes and best of luck!
Friedrich
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totka2
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Re: Treatment guidelines from Europe
« Reply #9 on: Sep 17th, 2007, 2:56pm » |
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on Sep 17th, 2007, 9:42am, cluster wrote:
Hello Steve,
I feel sorry that you have no access to "legal" O2 and think this a part of your civil rights to receive adequate medical treatment.
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Our "civil right" is maul halten und weiter gehen (shut up and go away) 
on Sep 17th, 2007, 9:42am, cluster wrote:
Tried and the ombudsman answered that a medicine's price - related question is political decision so he shouldn't encroach in this case. (Originally it was a three-line long period {oder großsatz})
PF
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