Oxygen treatment for cluster headache attacks at different flow rates: a double-blind, randomized, crossover study.

BACKGROUND: Cluster headache attacks can, in many patients, be successfully treated with oxygen via a non-rebreather mask. In previous studies oxygen at flow rates of both 7 L/min and 12 L/min was shown to be effective. The aim of this study was to compare the effect of 100% oxygen at different flow rates for the treatment of cluster headache attacks. METHODS: In a double-blind, randomized, crossover study, oxygen naïve cluster headache patients, treated attacks with oxygen at 7 and 12 L/min. The primary outcome measure was the percentage of attacks after which patients (treating at least 2 attacks/day) were painfree after 15 min, in the first two days of the study. Secondary outcome measures were percentage of successfully treated attacks, percentage of attacks after which patients were painfree, drop in VAS score and patient preference in all treatment periods (14 days). RESULTS: Ninety-eight patients were enrolled, 70 provided valid data, 56 used both flow rates. These 56 patients recorded 604 attacks, eligible for the primary analysis. An exploratory analysis was conducted using all eligible attacks of 70 patients who provided valid data. We could only include 5 patients, treating 27 attacks on the first two days of the study, for our primary outcome, which did not show a significant difference (p = 0.180). Patients tended to prefer 12 L/min (p = 0.005). Contradicting this result, more patients were painfree using 7 L/min (p = 0.039). There were no differences in side effects or in our other secondary outcome measures. The exploratory analysis showed an odds ratio of being painfree using 12 L/min of 0.73 (95% CI 0.52-1.02) compared to 7 L/min (p = 0.061) as scored on a 5-point scale. The average drop in score on this 5-point scale, however, was equal between groups. Also slightly more patients noticed, no or not much, relief on 7 L/min, and found 12 L/min to be effective in all their attacks. CONCLUSION: There is lack of evidence to support differences in the effect of oxygen at a flow rate of 12 L/min compared to 7 L/min. More patients were painfree using 7 L/min, but our other outcome measures did not confirm a difference in effect between flow rates. As most patients prefer 12 L/min and treatments were equally safe, this could be used in all patients. It might be more cost-effective, however, to start with 7 L/min and, if ineffective, to switch to 12 L/min. TRIAL REGISTRATION: European Union Clinical Trials Register ( 2012-003648-59 ), registered 1 October 2012. Dutch Trial Register ( NTR3801 ), registered 14 January 2013.

Post-Operative Cluster Headache Following Carotid Endarterectomy.

BACKGROUND: Secondary cluster headache following carotid endarterectomy (CEA) is a rare condition and may help us understand the pathophysiology of primary cluster headache. SUMMARY: We describe 2 patients diagnosed with cluster headache, fulfilling the ICHD-IIIB criteria, following CEA. Neither of the patients had headache prior to surgery. They both responded to treatment with oxygen and verapamil. Recent medical literature does not describe any definite cases of cluster headache following CEA. Cluster-like headache has been reported in several studies in the 1990s. Recent studies in primary cluster headache patients show evidence for a central origin of cluster headache in which no peripheral drive seems necessary. Key Messages: Our findings may provide more insight into the pathophysiology and show how a peripheral cause may lead to cluster headache. We hypothesize a role of the trigemino-autonomic reflex. Damage to the carotid artery may activate this reflex and trigger cluster headache. Injury to the internal carotid artery may unleash attacks in patients who are predisposed to develop cluster headache. Further study on the subject is needed to resolve this issue.