Episodic cluster headache (ICHD-3 3.1.1) is defined by distinct symptomatic periods — lasting 7 days to several months — separated by symptom-free intervals of at least 3 months. This protocol addresses the acute attack when the initial therapeutic step has not met its target.
The patient has episodic cluster headache meeting ICHD-3 criteria 3.1.1: active symptomatic periods of 7 days to several months (most commonly 4–12 weeks) and symptom-free intervals of at least 3 months between bouts.
The initial acute approach — subcutaneous sumatriptan injection or high-flow 100% oxygen via nonrebreather mask — did not reach the required outcome:
Patient not pain-free or at mild pain within 15 minutes of treatment
the majority of patients experience an episodic pattern (80%, ICHD-3 3.1.1), with symptomatic periods (7 days to several months, most commonly 4-12 weeks) and symptom-free periods of variable duration (minimum of 3 months).
An alternative would be zolmitriptan (5 mg) or sumatriptan (20 mg) nasal spray, with the disadvantage of a slower onset than with injected sumatriptan.
nVNS is recommended for the treatment of acute attacks in episodic but not chronic cluster headache.
Weak recommendations based on consensus further include DHE nasal spray and lidocaine.
Nasal instillation into the ipsilateral nostril of 1 mL 4%-10% lidocaine solution with the patient positioned reclining 45 and 30-40 rotation toward the symptomatic side has been recommended for the reduction of acute symptoms.
Headache relief at 30 min was observed in 63% of patients treated with 10 mg of zolmitriptan (application into the contralateral nostril is recommended) compared with 48% treated with 5 mg of zolmitriptan and 30% treated with placebo.
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