Triptans for Acute Cluster Headache

Subcutaneous sumatriptan is superior to intranasal zolmitriptan for rapid (15 minute) responses in the acute treatment of cluster headache. Level of evidence: "A"

A Cochrane review [Abstract] 1 included 6 studies with a total of 525 subjects. The mean age of participants ranged from 40 to 44 years, and between 60% to 87% were men. All patients had cluster headache according to IHS criteria. All studies used a single dose of triptan to treat a cluster headache attack. The treatments used were subcutaneous (s.c.) sumatriptan 6 mg or 12 mg and intranasal (i.n.) zolmitriptan 5 mg or 10 mg, compared with placebo. No study directly compared one drug with another.

S.c. sumatriptan 6 mg vs placebo (n=131, 258 events): The proportion of attacks pain-free at 15 minutes after treatment: 48% of participants were pain-free and 75% had headache relief, vs. 17% and 32%, respectively, for placebo. NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. For the endpoint pain-free at 15 minutes, comparing results for s.c. sumatriptan 6 mg with i.n. zolmitriptan 10 mg gave the point estimate of p<0.0008, indicating superiority of s.c. sumatriptan.
S.c. sumatriptan 12 mg vs placebo (n=88, 176 events): 60% of attacks treated with sumatriptan and 20% treated with placebo were pain-free at 15 minutes. A total of 80% of attacks treated with sumatriptan and 32% treated with placebo achieved headache relief at 15 minutes. For the endpoint headache relief at 15 minutes, comparing results for s.c. sumatriptan 12 mg with i.n. zolmitriptan 10 mg gave the point estimate of p=0.003, indicating superiority of s.c.sumatriptan.
I.n. zolmitriptan 5 mg vs placebo (n=231, 228 events): The proportion of attacks pain-free at 15 minutes after treatment was 8% vs. 3% with placebo. The relative benefit of treatment compared with placebo was 2.6 (95% CI 0.80 to 8.5). The figures for headache relief at 15 minutes after treatment were 15% vs. 7% with placebo.
I.n. zolmitriptan 10 mg vs placebo (n=223, 223 events): The proportion of attacks pain-free at 15 minutes was 12% (range 3% to 22%) vs. 3% for placebo (range 0% to 6%).The figures for headache relief in 15 minutes were 28% with zolmitriptan and 7% for placebo. The relative benefit of treatment compared with placebo was 3.9 (95% CI 1.3 to 12). The NNTs for pain-free response at 30 minutes was 3.3 (2.4 to 5.4) and for headache relief at 15 minutes 4.9 (3.3 to 9.2).

Fewer participants needed rescue medication with triptans than with placebo (27% with 10 mg of oral or i.n. zolmitriptan and 42% with placebo; NNT=6.8, 3 trials, n=223; 12% with 6 mg or 12 mg s.c. sumatriptan and 41% with placebo; NNT=3.5, 2 trials, n=219). More patients experienced adverse events with triptans but they were generally of mild or moderate severity, when reported, and rarely led to withdrawal.