2022 Taiwan Guidelines for Acute and Preventive Treatment of Cluster Headaches

The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated Taiwan's guidelines for the acute and preventive treatment of cluster headaches on the basis of the principles of evidence-based medicine. The subcommittee assessed the quality of clinical trials and levels of evidence and referred to the treatment guidelines of other countries. Over the course of several panel discussions, the subcommittee members reached a consensus regarding the major roles of, recommended levels of, clinical efficacy of, adverse events in, and clinical precautions for the acute and preventive treatment of cluster headaches. Thus, the subcommittee updated the previous version of the guidelines published in 2011. Most cluster headaches occurring in Taiwan are episodic, and very few patients develop chronic cluster headaches. Cluster headaches cause extreme pain over a short period and are accompanied by ipsilateral autonomic symptoms; therefore, immediate treatment can provide considerable relief. Treatment options can be categorized into acute and preventive types. Among the treatment methods currently available in Taiwan for cluster headaches, high-flow pure oxygen inhalation has demonstrated the best evidence and effectiveness for acute attacks, followed by triptan nasal spray; therefore, these are recommended as first-line treatments. Oral steroids and suboccipital steroid injections can be used as transitional preventative treatments. Verapamil is recommended as a first-line treatment for maintenance prophylaxis. Drugs such as lithium, topiramate, and calcitonin gene-related peptide (CGRP) monoclonal antibodies are recommended as secondline treatments. Noninvasive vagus nerve stimulation is the recommended instrumental therapy. The effectiveness of surgical treatment, such as sphenopalatine ganglion stimulation, is supported by a high level of evidence; nevertheless, because few patients have chronic cluster headaches in Taiwan, no clinical records are available for use as a reference. Transitional prophylaxis and maintenance prophylaxis can be used simultaneously according to the individual condition of the patient, and the transitional prophylaxis can be gradually discontinued once the maintenance prophylaxis takes effect. Steroids should not be used for more than 2 weeks as transitional prophylaxis. Maintenance prophylaxis should be administered until the end of the bout period (no attacks for 2 weeks) and then gradually tapered off. Key words: cluster headaches, oxygen therapy, triptans, steroids, CGRP monoclonal antibodies, noninvasive vagus nerve stimulation.