Inhaled Oxygen and Cluster Headache Sufferers in the United States: Use, Efficacy and Economics

Results From the United States Cluster Headache Survey

Todd D. Rozen, MD, FAAN; Royce S. Fishman, BA


Headache. 2011;51(2):191-200. 

In This Article

Abstract and Introduction


Objective.—To present results from the United States Cluster Headache Survey concerning the use of inhaled oxygen as acute treatment for cluster headache (CH).
Background.—Several small clinic and community-based investigations have indicated that more than 50% of CH patients have never used oxygen for the treatment of their headaches. This statistic is alarming and the reasons why they have not tried oxygen have not been determined.
Methods.—The United States Cluster Headache Survey is the largest study ever completed looking at CH sufferers living in the United States. The total survey consisted of 187 multiple choice questions, 84 questions dealt with oxygen use, efficacy and economics. The survey was placed on a website from October to December 2008.
Results.—A total of 1134 individuals completed the survey (816 male, 318 female). Among them 868 patients had episodic CH while 266 had chronic CH. Ninety-three percent of survey responders were aware of oxygen as a CH therapy; however, 34% had never tried oxygen. Forty-four percent of patients had to suggest oxygen to their physicians to get prescribed. Twelve percent of physicians refused to prescribe oxygen. Fifty percent using oxygen never received training on proper use. Forty-five percent had to find their own source for oxygen. On prescriptions only 45% specified flow rate, 50% stated CH as diagnosis and 28% indicated mask type. Seventy percent of the surveyed population felt oxygen was effective but only 25% was presently using oxygen. Potential reasons for this finding include: oxygen is slow to onset; prescribed oxygen flow rates are too low for efficacy and most CH patients need to raise flow rates during attacks to achieve response. The efficacy of oxygen does not vary by the age of the patient, gender, the number of CH attacks per day, and smoking history. Episodic CH responds better and faster to inhaled oxygen than chronic CH. Oxygen plus a triptan may be more efficacious and faster at aborting a CH than a triptan alone. Sixteen percent of CH patients state that oxygen is unaffordable while 12% are getting welder grade oxygen because of costs of medical grade oxygen, and this form of oxygen could be potentially dangerous to the individual user.
Conclusions.—Oxygen is underutilized by CH patients living in the United States. Current recommended oxygen treatment regime is not meeting the needs of many CH patients. Prescribed oxygen flow rates are too low for efficacy. Oxygen can be expensive and very difficult to obtain. Physicians need to be better educated on the use of inhaled oxygen for CH.


Cluster headache (CH) is a primary headache disorder marked by excruciating attacks of short lived one-sided head pain with associated autonomic features. It is felt to be one of the most severe headache conditions that humans experience. Oxygen inhalation therapy is recognized as one of the 2 most effective abortive treatments for CH outside of injectable sumatriptan.[1] Oxygen therapy was first proposed for CH by Bayard Horton in the 1950s[2] and was made a mainstream treatment for CH by Kudrow in the early 1980s.[3] For many years the recommended inhaled oxygen flow rate for acute CH treatment was 7 liters per minute (L/minute). Recently, the first randomized placebo-controlled study of high flow oxygen at a rate of 12 L/minute was completed showing statistically significant improvement over placebo.[4] Other studies have shown efficacy up to 15 L/minute in CH patients who did not respond at lower flow rates.[5] Presently, inhaled oxygen given via a non-rebreather face mask at rates of 7 to 12 liters per minute for 20 minutes is the recommended dosing schedule and delivery system for acute CH treatment. As many CH sufferers have significant cardiovascular risk factors and thus may develop contraindications to the use of triptans, inhaled oxygen is an extremely valuable treatment tool for this primary headache syndrome. The high number of CH patients who present to dedicated headache clinics having never tried oxygen therapy is surprising. Equally surprising is if they have utilized oxygen, it was given via a nasal cannula or at a delivery flow rate below what is suggested. At present we have no published data on the use of inhaled oxygen in any large CH population and specifically nothing from the United States. The goal of this present study was to abstract data from the United States Cluster Headache Survey, the largest survey ever completed looking at CH patients living in the United States, to better understand oxygen usage by this population.[6] Questions that were looked at included: What is the percentage of CH patients who have actually tried oxygen therapy? What is actually being prescribed to CH patients by physicians? What is the efficacy of oxygen therapy? And what is the financial cost of oxygen therapy for CH patients?


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