Page 316 Acute Pain Management

Triptans
SC sumatriptan injection (Ekbom, 1995 Level II) or IN sumatripan spray (van Vliet et al, 2003
Level II) were effective first‐line treatments for cluster headache attacks, with SC
administration providing faster onset and greater reliability of analgesia (Hardebo & Dahlof,
1998 Level II). IN zolmitriptan was rapidly effective (Cittadini et al, 2006 Level II; Rapoport et al,
2007 Level II) and oral zolmitriptan was effective in treating ‘episodic’ but not chronic cluster
headache (Bahra et al, 2000 Level II). Increased age was associated with a reduced response to
triptans (Schurks et al, 2007 Level IV).
Other treatments
There have been no RCTs of ergotamines in the treatment of cluster headache, although
injectable or IN dihydroergotamine may be of benefit (its use has been superseded by
sumatriptan) (Dodick et al, 2000). IN (Dahlof, 2002) or IV (May et al, 2006) lignocaine may be
effective. A single suboccipital steroid injection with betamethasone completely suppressed
cluster headache attacks in 80% of patients for weeks, compared with a placebo control
injection (Ambrosini et al, 2005 Level II).
Bilateral occipital nerve stimulation has been used successfully to treat otherwise intractable
cluster headaches (Burns et al, 2009 Level IV).
Paroxysmal hemicrania and SUNCT
Paroxysmal hemicrania and SUNCT are rarer forms of trigeminal autonomic cephalalgia.
Paroxysmal hemicrania is similar to cluster headache except that it is more common in
females, episodes are shorter but more frequent, and diagnosis requires the complete
abolition of symptoms with indomethacin (Headache Classification Subcommittee of the IHS, 2004),
which is the suggested treatment of choice (May et al, 2006). There is no high‐level evidence to
guide the treatment of SUNCT, however consensus guidelines based on case‐series data
suggest that lamotrigine or possibly topiramate or gabapentin may be useful prophylactics
(May et al, 2006).
Postdural puncture headache
PDPH usually following spinal anaesthesia, inadvertent dural puncture with an epidural
CHAPTER 9 of approximately 0.7% to 50%, (Halpern & Preston, 1994 Level I; Gaiser, 2006); up to 90% of cases
needle, diagnostic or therapeutic lumbar puncture or neurosurgery, occurs with an incidence

improve spontaneously within 10 days (Candido & Stevens, 2003).
PDPH is more common in patients under 50 years of age and parturients (Candido & Stevens,
2003), and following inadvertent dural puncture with an epidural needle. The odds of
developing PDPH are significantly lower in males compared with (non‐pregnant) females
(Wu et al, 2006 Level I). A history of previous PDPH significantly increases the risk of developing
a headache with subsequent spinal anaesthesia (Amorim & Valenca, 2008 Level IV). Children who
undergo lumbar puncture may present a special group (Janssens et al, 2003).
Spinal needle size, type and lumbar puncture technique
Data from the anaesthesiology and neurology literature indicate that needle calibre, bevel
type and lumbar puncture technique affects the incidence of PDPH. The incidence of PDPH
following spinal anaesthesia was reduced significantly by using a smaller gauge needle
(26 gauge or less [NNT: 3]) or a needle with a ‘non‐cutting’ bevel (eg ‘pencil point’) (NNT: 27)
(Halpern & Preston, 1994 Level I). The incidence of PDPH was also reduced by orientating the
cutting bevel parallel to the spinal saggital plane (dural fibres) (Richman et al, 2006 Level I) or by
replacing the stylette prior to withdrawing a non‐cutting needle (Strupp et al, 1998 Level II); both
of these techniques (presumably) reduced cerebrospinal fluid (CSF) loss.

268 Acute Pain Management: Scientific Evidence