The answer is D: high flow oxygen and subcutaneous sumatriptan
Cluster headache is thought by many authorities to be a migraine variant. Injectable sumatriptan is the only injectable triptan currently available and is the drug of choice for acute episodes of cluster headache. Also, inhalation of 7 to 15 L/minute of 100% oxygen with a non-rebreather facial mask can be beneficial in an acute cluster attack. Ergotamine preparations have also been shown to be effective, but oxygen and subcutaneous sumatriptan have a faster onset of action and are the first line in treatment.
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Pearls
- Unilateral, excruciating, sharp, searing, or piercing pain (often at night), lacrimation, and nasal congestion
- Males > Females
- Often awakes in middle of night
Treat with oxygen 100% at 6–12 L/min for 15 minutes via nonrebreathing mask provides relief within 15 minutes and Imitrex
Diagnosis
- Diagnosis is based on the distinctive symptom pattern and exclusion of intracranial abnormalities
Treatment
Oxygen
- 100% at 6–12 L/min for 15 minutes via nonrebreathing mask provides relief within 15 minutes.Avoid in severe chronic obstructive pulmonary disease (COPD) as might affect hypoxic respiratory drive.
Sumatriptan (Imitrex)
- 6 mg SC, max 12 mg/24 hr with at least 1 hour between injections is most effective medication for acute attacks.Sumatriptan nasal spray: 20 mg. May repeat in 2 hours, max dose 40 mg/24 hr.
Zolmitriptan (Zomig)
- Nasal spray: 5- and 10-mg dosage both effective. May repeat in 2 hours, max 10 mg/24 hr.Zolmitriptan tablet: 5- and 10-mg dosage both effective. May repeat in 2 hours, max dose 10 mg/24 hr.
For long-term prophylaxis, verapamil, lithium, topiramate, divalproex, or a combination
