Update on the therapy of the trigeminal autonomic cephalalgias.

The treatment of trigeminal autonomic cephalalgias requires very careful attention to clinical aspects. It is important to spend enough time assessing the patient to arrive at an accurate diagnosis. Identifying trigger factors (eg, alcohol), when applicable, is part of the therapy, as behavior modifications may be necessary. Cluster headache treatment should never be delayed; patients should be able to visit the clinic within 48 hours to expedite medication initiation. Abortive therapy typically is best achieved with nasal oxygen, sumatriptan injections, or both. Typically, a steroid taper is begun and will be continued for a few days. A prophylactic agent such as verapamil or topiramate also is initiated immediately and will be taken for a period slightly beyond the expected duration of the last cluster period before an attempt is made to taper it off. For chronic cluster headache, lithium carbonate is recommended after a few weeks if these other treatments have failed. If more than three regimens of medical therapy fail, patients should be considered for neurostimulation procedures. Paroxysmal hemicrania most often responds to indomethacin. Failure may be due to a dosage that is too low. Gastric protection should always be given, because this medication has a high rate of gastric complications. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) remain very difficult to treat. Lamotrigine is the first recommendation. Overall, one of the most crucial aspects of the management of patients with these disabling headache syndromes is patient education regarding what their disorder is and the reasoning behind the therapeutic options offered.