Cluster headache (CH) is one of the most severe pain conditions known to mankind. The suffering of the patient is enormous, which places special demands on the treating physician as regards his or her empathy and understanding of the patient’s whole situation. The individual attacks are relatively brief but are usually of such high intensity that treatment of symptoms may fail to have the desired effect (1). Many patients have a high consumption of analgesics, which implies certain risks in the case of lengthy periods of headache. Information to the patient on the nature of CH is important, among others, to optimize compliance to different treatment regimes. Alcohol can bring on extra attacks and should not be consumed during active periods of CH. Afternoon naps should also be avoided. It is important to relieve the patient’s fear and anxiety of the attacks and to inform that CH, although severe, is self-limiting and does not give rise to structural complications.

As with migraine, medical treatment can be divided into the following:

1. Acute symptomatic treatment of individual attacks

2. Prophylactic treatment

The spontaneous course of CH may cause some problems when evaluating effects of treatment. It may, for example, be somewhat difficult to decide whether an observed improvement is due to effects of drugs or to a spontaneous remission. Patients should be encouraged to keep a headache diary, and it is necessary to reevaluate the treatment of the patients on every visit. Dosage of the drugs used and the administration mode should be individualized and adapted to the rhythm of the attacks. When choosing pharmacologic treatment, attention should be paid to the patient’s age, state of health, the type of disease (episodic or chronic CH), the frequency and duration of the attacks, their time of occurrence, and the expected length of the remaining CH period. Because the pattern of attacks varies considerably from one patient to another, an effective prophylaxis may be difficult to achieve, especially in the case of frequent, severe attacks or extended periods of headache.

Attacks of CH are very rapid in onset and peak in less than 5 to 10 minutes. Oral medications are, in general, to slow to work and therefore not appropriate for treatment of acute attacks. Patients want simple self-administered drugs with high efficacy and a safe, rapid, and consistent action. In most CH patients, sumatriptan 6 mg subcutaneously is the pharmacologic agent of first choice in the treatment of acute attacks (2). Sumatriptan is given as a sole acute medication or added to prophylactic management. It is well tolerated and there is no evidence of any tachyphylaxis on long-term treatment. It should be remembered that sumatriptan is an expensive drug. If injectable sumatriptan is not tolerated, a rapid-acting triptan nasal spray may be useful as an alternative therapy (4,8,9,11).