Triptans for acute cluster headache

Abstract

Background: Cluster headache is an uncommon, but severely painful and disabling condition, with rapid onset. Validated treatment options are limited, and first-line therapy includes inhaled oxygen. Alternative therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and, because of this, they may also be useful for cluster headache.

Objectives: To determine the efficacy and tolerability of triptans for the acute treatment of cluster headaches.

Search strategy: We searched Cochrane CENTRAL, MEDLINE and EMBASE for studies through 22 January 2010.

Selection criteria: Randomised, double-blind, placebo-controlled studies of triptans for acute treatment of cluster headache episodes.

Data collection and analysis: Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief, requiring rescue medication and experiencing adverse events and headache-associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat (NNT) and harm (NNH).

Main results: All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. In total 231 participants received zolmitriptan 5 mg, 223 received zolmitriptan 10 mg, 131 received sumatriptan 6 mg, 88 received sumatriptan 12 mg, and 326 received placebo. Zolmitriptan was administered either orally or intranasally, and sumatriptan either subcutaneously or intranasally.Overall, the triptans studied were better than placebo for headache relief and pain-free responses, with an NNT of 2.4 for 15 minute pain relief with subcutaneous sumatriptan 6 mg (75% with sumatriptan and 32% with placebo), and 2.8 for 30 minute pain relief with intranasal zolmitriptan 10 mg (62% with zolmitriptan and 26% with placebo). Fewer participants need rescue medication with triptan than with placebo, but more experienced adverse events.

Authors' conclusions: Zolmitriptan and sumatriptan are effective in the acute treatment of cluster headaches and may provide a useful treatment option, potentially offering convenience over oxygen therapy and a better safety and tolerability profile than ergotamine. Non-oral routes of administration are likely to provide better and more rapid responses.

Figure 1. Methodological quality graph: review authors’ judgements about each methodological quality item presented as percentages across all included studies

Figure 2. Forest plot of comparison: 1 Zolmitriptan 5 mg versus placebo, outcome: 1.1 Participants with headache relief at 30 minutes

Figure 3. Forest plot of comparison: 2 Zolmitriptan 10 mg versus placebo, outcome: 2.1 Participants with headache relief at 30 minutes

Figure 4. Forest plot of comparison: 4 Sumatriptan 6 mg versus placebo, outcome: 4.1 Participants with headache relief at 15 minutes

Figure 5. Forest plot of comparison: 1 Zolmitriptan 5 mg versus placebo, outcome: 1.2 Participants pain-free at 30 minutes

Figure 6. Forest plot of comparison: 4 Sumatriptan 6 mg versus placebo, outcome: 4.2 Participants pain-free at 15 minutes