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comparing oxygen with inhaled room air provided further evidence of
oxygen’s superiority over placebo in CH therapy. 10 Given these data and
the safety profile of inhaled oxygen, it should be used as an adjunctive
treatment in virtually all cases of CH.
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While hyperbaric oxygen has been investigated for CH treatment, the
current evidence provides insufficient basis for recommending its use for
this indication. 11
The somatostatin analog octreotide has been shown to inhibit vasopeptides
released during CH episodes. An RCT showed that octreotide (100 mcg
SC) was superior to placebo in aborting CH pain. 12 Although there is no
direct comparison between octreotide and the triptans, testing of these
agents against placebo suggests that the triptans are superior in both number
of responders and the time to onset of action. However, given the contraindications
of triptan use in patients with vascular disease, there is at least an
occasional role for octreotide in CH.
Numerous ergot alkaloids have been used for treatment of CH. The only
agent that has been recently studied is the inhaled form of the ergot derivative
dihydroergotamine. An RCT found 1 mg IN superior to placebo for
relief of CH. 13
Results from an uncontrolled, open-label study suggest a potential role for the
atypical antipsychotic olanzapine in CH. The data are preliminary, so recommendation
for olanzapine in acute therapy of CH must await further evidence. 14
NSAIDs are potentially useful in some rare headache types (e.g. chronic
paroxysmal hemicrania) that are similar to CH, but the current balance of
evidence argues against utility of indomethacin or other NSAIDs in true
CH. 15,16 Though the literature (and even the nosology) of acute hemicrania
continues to evolve, there is at this time little basis for use of NSAIDs in acute
presentations of CH.
Although there is anecdotal experience with use of benzodiazepines, no
supporting evidence exists for their use in CH.
The use of opioids for CH is anecdotally reported for CH and variants. 17,18
Although there is no evidence supporting a recommendation for routine use
of this class in CH, there may be occasional utility of opioids for severe or
refractory CH.