Patients will need your help managing CLUSTER HEADACHES. They're called "suicide headaches" because the pain is so severe. Cluster headaches almost always occur on one side of the face by the eye and cause tearing, runny or stuffy nose, and restlessness. Attacks don't last as long as a migraine. But they usually occur in clusters of weeks to months, with months or years between clusters.
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Cluster headaches are classified as chronic (attacks continue for > 1 year with remission lasting < 1 month) or episodic (clusters of seven days to one year, with at least one month between clusters).
Acute TREATMENT of an attack includes a triptan, oxygen, or both. Start with injectable sumatriptan (Imigran, Sumatriptan, etc) 6 mg and may be used up to 2 times a day or intranasal zolmitriptan (Zomig) 5 mg up to 2 times or sumatriptan. Lean away from oral triptans, they don't work as fast, and these headaches peak rapidly.
Inhaling 100% oxygen also provides prompt relief. Help arrange for patients to get an oxygen tank for home use. Include diagnosis, oxygen flow rate, duration, etc., on the order. Expect about 12 L/min for 15 minutes to be effective for most patients. Avoid NSAIDs or opioids, they usually don't help. Also consider "bridge therapy", usually with a 2- to 3-week taper of prednisone (Solupred) as 70 mg daily for 4 days, then reduce daily dose by 5 mg every day (17 days course) if the patient has more than 2 attacks per day. This can quickly stop a cluster while you're titrating preventive medications.
Start PROPHYLAXIS when the cluster begins to limit future attacks. Use verapamil (Isoptin) 240 mg/day in divided doses and titrate about every one to two weeks, usually to 480 mg/day. Lithium (Prianil CR) 300 mg twice a day AS STARTING dose seems to work as well as verapamil and increase to 300 mg 3 times a day after 1 week if no response. But it has a slower onset, more side effects, and requires lab monitoring (do lithium blood levels and increase further if necessary [usual therapeutic range 0.4-0.8 mEq/L]). Continue prophylaxis for patients who have clusters every couple of months. For patients with longer "breaks", slowly taper off once they've been pain-free for at least a few weeks.
REFERENCES
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Robbins MS, Starling AJ, Pringsheim TM, Becker WJ, Schwedt TJ. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache. 2016 Jul;56(7):1093-106. Available at: https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.12866
Obermann M, Holle D, Naegel S, Burmeister J, Diener HC. Pharmacotherapy options for cluster headache. Expert Opin Pharmacother. 2015 Jun;16(8):1177-84. Available at: https://www.tandfonline.com/doi/abs/10.1517/14656566.2015.1040392?journalCode=ieop20
Becker WJ. Cluster headache: conventional pharmacological management. Headache. 2013 Jul-Aug;53(7):1191-6. Available at: https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.12145