Cluster Headache—Acute and Prophylactic Therapy

Avi Ashkenazi, MD; Todd Schwedt, MD


Headache. 2011;51(2):272-286. 

In This Article

Ergotamine and Dihydroergotamine

Ergot derivatives were among the first agents to be used in CH treatment. Reports on the efficacy of ergotamine for this indication date back to the 1940s and 1950s.[1] These data, however, were based on small, open-label studies and on case reports. The drug has not been evaluated in controlled studies for this indication. Kudrow compared the efficacy of sublingual ergotamine with that of oxygen in 50 patients with CH.[17] The response rate to ergotamine was 70%, as compared with 82% for oxygen (with no significant between-group difference). Oxygen was better tolerated than ergotamine; however, the latter was more convenient to use. Because of limited availability and potentially serious AEs, most notably those related to the drug's vasoconstrictive effect, ergotamine is currently rarely used for acute CH.

Dihydroergotamine (DHE) is available in injectable (intravenous, intramuscular, or subcutaneous) and intranasal formulations. Although no data from controlled trials are available, clinical experience suggests efficacy of intravenous DHE for acute CH. This treatment, however, is not practical for the majority of patients because of the difficulty in receiving it promptly with attack onset. Based on our clinical experience, intramuscular and subcutaneous DHE injections are not as effective as the intravenous route, although, to our knowledge there are no studies that compared the various routes of administration of the drug for CH. The efficacy and tolerability of intranasal DHE (1 mg) in the treatment of acute CH was examined in a controlled study of 25 patients.[24] Intranasal DHE decreased the intensity, but not the duration, of the attacks, and was well tolerated. The authors suggested that the moderate efficacy of the drug in their study may have been related to the dose they used. They recommended that the drug be examined at a higher dose in future trials (the maximal recommended dose of intranasal DHE for acute headache treatment in adults is 2 mg).

In summary, because of the moderate efficacy of most ergot preparations and the difficulty of receiving intravenous DHE (probably the most effective preparation for this purpose) in a timely manner, the role of ergots in the acute treatment of CH is limited.


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