Mampreso E, Maggioni F, Viaro F, Disco C & Zanchin G (2009) “Efficacy of oxygen inhalation in sumatriptan refractory ‘high altitude’ cluster headache attacks” J Headache & Pain 10:465-467 (Click author to see paper)
AUTHORS’ ABSTRACT: We describe the case of a 40-year-old woman, affected by episodic cluster headache, who presented with a cluster headache triggered by exposure to high altitude. Her attacks were refractory to sumatriptan, very effective at sea level, but responded to oxygen. A pathophysiological mechanism is proposed.
Dr. Sewell’s comment:
This is a case of a 40-year-old woman who had had episodic cluster headache since age 25, with one or two attacks a day for three weeks a year. Always, she treated them with sumatriptan (Imitrex) injection; always, sumatriptan did the trick.
Until, that is, she drove up into the mountains. At about 1,400 meters (4,600 feet), an attack started, and she found—for the first time in her life—that sumatriptan wasn’t working any more. The next day, while still up in the mountains, she had two more attacks, and sumatriptan didn’t work for those either! So she called Dr. Mampreso, the author of the case report, who gave her oxygen (7 L/min), which worked within five minutes—and she was able to treat every attack after that the same way.
The following week, she came down from the mountains, and sumatriptan started to work for her again.
What can we take from this? Both oxygen and triptans are believed to work by constricting blood vessels. Triptans stimulate the serotonin 1B receptor, which is located in the wall of blood vessels and causes them to constrict. It’s not clear how oxygen makes blood vessels constrict. Three years ago, Dr. Schürks at the University of Essen in Germany published a study in which he found that responsiveness to triptans (such as Imitrex) did not predict responsiveness to oxygen, nor the other way around, which suggests that the mechanism of action is different for the two treatments. A recent study by Dr. Akerman in an animal model of cluster headache (see Akerman) found that oxygen did not affect the trigeminal nerve, which carries pain from the face, but did have an effect on nerves that projected to blood vessels in the brain, stopping both the constriction and also the autonomic activation (droopy eye, runny nose, etc.) that we see during cluster attacks. And now this case report is more evidence that oxygen and triptans cause blood vessel constriction by different mechanisms.
Most cluster headache patients have had the experience of getting on a plane and having a cluster attack happen in mid-flight from the low oxygen pressure. Most have had the same problem when visiting a higher altitude as well. It may be that the best treatment for altitude-induced cluster attacks is oxygen, rather than medication.
One final note—this patient found relief from oxygen at 7 L/min. Dr. Todd Rozen, Director of the Headache Program at the Geisinger Medical Center has argued that much higher flow rates can be helpful, up to 15 L/min, and I agree—so if you’re one of the people who finds that oxygen doesn’t help, don’t give up on it till you try the higher flow rate!
I have experienced some of the worst CH ever when in the mountains of Georgia and North Carolina – places I used to visit before I became chronic in 2003. This at less than 5,000 feet.
However, I did not have problems in Montana up to 9,000 feet, or in Costa Rica, at 5,000 ft. I can’t figure that out!
So far, no trouble flying.
On your advice, Dr. Sewell, I use 12-15/lpm (not the 4/lpm my local neurologist suggested. It is usually successful in aborting a headache in 10-15 minutes, which can seem like a lifetime. Sometimes the mask causes pain on the trigeminal even though it is padded.
Your advice to keep on trying at a higher dose is GREAT advice! I educated the 2 different neurologists I have seen.
Sandi Suddaby
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