The Usual Treatment of Trigeminal Autonomic Cephalalgias

Trigeminal autonomic cephalalgias include cluster headache, paroxysmal hemicrania, and short‐lasting unilateral neuralgiform headache attacks with conjunctival injection, tearing, and rhinorrhea ( SUNCT ). Conventional pharmacological therapy can be successful in the majority of trigeminal autonomic cephalalgias patients. Most cluster headache attacks respond to 100% oxygen inhalation, or 6 mg subcutaneous sumatriptan. Nasal spray of sumatriptan (20 mg) or zolmitriptan (5 mg) are recommended as second choice. The bouts can be brought under control by a short course of corticosteroids (oral prednisone: 60‐100 mg/day, or intravenous methylprednisolone: 250‐500 mg/day, for 5 days, followed by tapering off the dosage), or by long‐term prophylaxis with verapamil (at least 240 mg/day). Alternative long‐term preventive medications include lithium carbonate (800‐1600 mg/day), methylergonovine (0.4‐1.2 mg/day), and topiramate (100‐200 mg/day). As a rule, paroxysmal hemicrania responds to preventive treatment with indomethacin (75‐150 mg/day). A short course of intravenous lidocaine (1‐4 mg/kg/hour) can reduce the flow of attacks during exacerbations of SUNCT . Lamotrigine (100‐300 mg/day) is the preventive drug of choice for SUNCT . Gabapentin (800‐2700 mg/day), topiramate (50‐300 mg/day), and carbamazepine (200‐1600 mg/day) may be of help.