Inhalation of 100 percent oxygen via mask for 10 to 15 min at the onset of cluster headache may abort the attack, but this is not always practical. Termination of a cycle of cluster can also be achieved with verapamil, starting with 80 mg qid and increasing the dose over days, but electrocardiogram (ECG) monitoring is recommended in the older individual. The usual nocturnal attacks of cluster headache can be treated with a single anticipatory dose of ergotamine at bedtime (2 mg orally) or with possibly lesser efficacy, an equivalent dose of serotonin agonist. Intranasal lidocaine or sumatriptan (or zolmitriptan as for migraine, see above) can also be used to abort an acute attack. In other patients, ergotamine given once or twice during the day, before an attack of pain is expected, has been helpful.
With regard to prevention of cluster headache, if ergotamine and sumatriptan are ineffective or become ineffective in subsequent bouts, many headache experts prefer to use verapamil, up to 480 mg/d. Ekbom introduced lithium therapy for cluster headache (600 mg, up to 900 mg daily), and Kudrow has confirmed its efficacy in chronic cases. Lithium and verapamil may be given together, but lithium toxicity is a frequent problem. A course of prednisone, beginning with 75 mg daily for 3 days and then reducing the dose at 3-day intervals, has been beneficial in many patients. Usually, it can be decided within a week if any one of these medications is effective. In brief, no method is effective in all cases, but the best initial approach probably involves the use of one of the triptan compounds. Rare cases of intractable cluster headache, in which the syndrome persists for weeks or longer without remission, have been treated by partial section of the trigeminal nerve, as described by Jarrar and colleagues, but these ablative measures are now always a last resort, especially when hypothalamic stimulation has been shown to be possibly effective, as mentioned earlier.
This, said to be the most common variety of headache, is usually bilateral, with occipitonuchal, temporal, or frontal predominance, or diffuse extension over the top of the cranium. The pain is usually described as dull and aching, but questioning often uncovers other sensations, such as fullness, tightness, or pressure (as though the head were surrounded by a band or clamped in a vise) or a feeling that the head is swollen and may burst. On these sensations, waves of aching pain are superimposed. These may be interpreted as paroxysmal or throbbing and, if the pain is slightly more on one side, the headache may suggest a migraine without aura. However, absent in tension headache are the persistent throbbing quality, nausea, photophobia, phonophobia, and clear lateralization of migraine. Nor do most tension headaches seriously interfere with daily activities, as migraine does. The onset is more gradual than that of migraine, and the headache, once established, may persist with only mild fluctuations for days, weeks, months, or even years. In fact, this is the only one of the few types of headache that exhibits the peculiarity of being present throughout the day, day after day, for long periods of time for which the term chronic tension-type headache is used. There is often self-acknowledged anxiety and depression, as noted below. Although sleep is usually undisturbed, the headache develops soon after awakening, and the common analgesic remedies have limited effect if the pain is of more than mild to moderate severity.