Cluster Headache and Cluster Variants.
Patients must be cognizant of the time course of the cluster headache periods to optimally tailor their therapy. Steroids provide the fastest onset of prophylactic effect. Once steroids are initiated, it remains difficult to wean patients off of them, and that is why it is always recommended to associate another prophylactic agent from the onset with the steroids. All triptans can be considered; however, only injectable sumatriptan and zolmitriptan have been the subject of controlled studies, and the former remains the gold standard because of its speed of action. Lithium, although not a first-line therapy, remains mainly efficacious for the chronic form of cluster headache. There does not seem a significant tendency for analgesic rebound-withdrawal headache with cluster headache compared with migraine. Scientific studies of the treatment of cluster headache are inherently difficult because of the rarity of the syndrome, the short duration of attacks, and the relatively short duration of the cluster period, along with the presence of spontaneous remissions. Moreover, still a significant proportion of the available evidence on this subject is uncontrolled. Active, rather than placebo, control individuals are recommended. As far as surgical procedures are concerned, although only recently introduced and less documented, gamma-knife radiosurgery should be preferred to the procedures associated with craniotomy, which are inherently associated with a higher complication potential risk.