Oxygen

Hyper- or normobaric oxygen therapy to treat migraine and cluster headache pain : Cochrane Review.

Schnabel A, Bennet M, Schuster F, Roewer N, Kranke P.

Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Münster, Deutschland.

BACKGROUND: The aim of this systematic review was to assess the benefits and harms of supplemental oxygen (HBOT/NBOT) for treating and preventing migraine and cluster headaches.

MATERIAL AND METHODS: All randomized trials comparing the effect of supplemental oxygen on migraine or cluster headache with those that exclude supplemental oxygen were included in this review. The systematic search included all relevant sources according to the paradigms of the Cochrane Collaboration. Data were analyzed with RevMan 4.2.

RESULTS: Nine trials involving 201 participants satisfied the inclusion criteria. HBOT was effective in relieving an acute migraine and seemed to be sufficient in the treatment of an acute cluster attack. NBOT was effective in terminating acute cluster headache compared to sham treatment, but not in comparison to sublingual ergotamine. There was no evidence for any prophylactic effects. Serious adverse effects were not noted in the trials investigated.

CONCLUSIONS: There is some evidence that HBOT is effective for termination of acute migraine. NBOT was similarly effective in cluster headache, however with sparse data. Because of costs and poor availability HBOT cannot be regarded as a routine therapy. Further indications in the case of treatment failure using standard therapy need to be defined based on data of future clinical trials.

PMID: 17885769

Martha Sue McLeod, Frank Andrasik, Russel C. Packard, Bayard D. Miller

Research has shown that inhalation of pure oxygen is effective in aborting cluster headache. This article advances the hypothesis that cooling is the critical ingredient behind the effectiveness of oxygen inhalation, rather than the oxygen concentration. To test this hypothesis, eight cluster headache participants used a device that delivered cooled room air as a means to abort headache attacks. Additionally, six of the subjects administered pure oxygen so that comparisons could be made to the air-cooling device. The proportion of cases in which subjects attained effective relief from cluster headache pain by use of the air-cooling device was significantly higher than the proportion of cases in which subjects did not attain effective relief from headache pain. There was no significant difference between the proportion of headaches relieved by oxygen and the proportion of headaches relieved by the air-cooling device. This study raises questions about the mechanisms of action of oxygen inhalation for treating cluster headache, and indicates that future clinical investigations into the use of cold room air for treating cluster headache pain are warranted.

Historical Development Of Normobaric Oxygen In The Symptomatic Treatment Of Cluster Headache

DJ Capobianco Jacksonville, FL

Objective: - Review the historical development of normobaric oxygen in the acute treatment of cluster headache.

Background: - The use of normobaric oxygen in the treatment of headache can be traced back to Drs. Boothby, Alvarez, and Horton of the Mayo Clinic.

Method: - Review of published papers.

Results: - In 1938, under the direction of Walter M. Boothby, MD, oxygen therapy was employed in the symptomatic treatment of headache. Alvarez reported the beneficial response of 100% oxygen, delivered at a flow rate of between 6 to 8 liters per minute, as abortive treatment for headache [1]. Unfortunately, it is difficult to know if this included patients with cluster headache. Bayard T. Horton was the first to note that inhaling 100% oxygen alleviated a cluster attack, if taken during the initial headache phase [2]. Friedman and Mikropoulos [3] and later, Graham [4], also noted this beneficial response of oxygen inhalation for cluster headache. In 1978, an optometrist, Jerold F. Janks, published his own personal account of oxygen's beneficial role in the treatment of cluster headache [5]. Kudrow elaborated further on Horton's finding. He noted that 75% of outpatients treated with 100% oxygen administered via face mask at 7 liters per minute, experienced complete or near complete relief within 15 minutes [6]. Anthony found that oxygen inhalation was beneficial in all 12 patients studied [7]. Fogan, in the only double-blind control study, demonstrated that oxygen inhalation provided complete or substantial relief in at least 80% of patients' cluster attacks [8].

Conclusion: - Bayard T. Horton deserves credit for discovering the beneficial role of oxygen inhalation in the symptomatic treatment of cluster headache. The elegant work of Drs. Kudrow, Anthony, and Fogan further corroborated Horton's initial findings.

References:
[1] Alvarez WC, Mason AY. Results obtained in the treatment of headache with the inhalation of pure oxygen. Mayo Clin Proc. 1940;15:616-618.
[2] Horton BT. Histaminic cephalgia. Lancet. 1952;72:92-98.
[3] Friedman AP, Mikropoulos HE. Cluster headaches. Neurology. 1958;8:653-663.
[4] Graham JR. Cluster headache. In: Appenzeller O, ed. Pathogenesis and Treatment of Headaches. New York: Spectrum Publications; 1976:93-108.
[5] Janks JF. Oxygen for cluster headaches. JAMA. 1978;239:191.
[6] Kudrow L. Response of cluster headache attacks to oxygen inhalation. Headache. 1981;21:1-4.
[7] Anthony M. Treatment of attacks of cluster headache with oxygen inhalation. Clin Exp Neurol. 1981;18:195.
[8] Fogan L. Treatment of cluster headache. A double-blind comparison of oxygen vs air inhalation. Arch Neurol. 1985;42:362-363.

The present study concerns the possible relationship between hypoxia and the generation of cluster headache attacks. Fifteen controls and 25 cluster headache patients were studied. The patients were allocated into two groups according to cluster headache stage, i.e. cluster or remission period. During the tests, all the subjects were asked to inhale 12% oxygen (88% N2) for 30 min, and the decreasing oxygen saturation (SaO2%) was monitored. Patients in the remission period showed nearly the same decrement of SaO2% as controls. At the end of the test, patients in the bout showed significantly less reduction of SaO2% than the controls. In 5 patients, the test was carried out both in and outside the cluster periods. The tendency to less decrement in oxygen saturation in the cluster phase was as marked with this comparison, but the difference between the groups was not significant, probably partly due to the low number of tests carried out. Only one patient got a typical attack. It seems that hypoxia of this magnitude per se is not the cause of attacks. The different pattern with respect to SaO2% following 12% O2 inhalation in cluster headache may be due to an abnormality in central regulation and/or chemoreceptor sensitivity.

Cluster headache and chronic paroxysmal hemicrania--effectiveness of oxygen inhalation.

Heckl RW

Ten patients suffering from cluster headache or variants of cluster headache were made to inhale oxygen in an attempt to check these attacks. This treatment proved a success with six patients with classic ("episodic") cluster headache, as well as with another patient suffering from secondary chronic cluster headache. One patient with primary chronic cluster headache and another with chronic paroxysmal hemicrania (PCH) experienced only temporary relief and a female patient with PHC showed no reaction to oxygen inhalation. The patient who suffered from secondary chronic cluster headache has had no further attacks in the four years following this treatment.

Arch Neurol. 1985 Apr;42(4):362-3.

Treatment of cluster headache. A double-blind comparison of oxygen v air inhalation.

Fogan L

Nineteen men, aged 20 to 50 years, were treated in a double-blind crossover study comparing oxygen v air inhalation at 6 L/min via nonrebreathing face masks for 15 minutes or less, for up to six headaches. Patients scored their own degree of relief for each treatment as none, slight, substantial, or complete relief. The average (+/- SE) relief score for all oxygen-treated patients was 1.93 +/- 0.22 out of a possible total score of 3.0, and for air the treatment relief score was 0.77 +/- 0.23. This difference is highly statistically significant by an analysis-of-variance F test; it documents that patients with cluster headache can benefit from oxygen inhalation during acute attacks.

PMID: 3885921

California Medical Clinic for Headache, 16542 Ventura Boulevard, Encino, California. (213) 986-4248.

Fifty-two randomly selected patients diagnosed as having either active episodic or chronic cluster headaches were evaluated for symptomatic response to oxygen inhalation. At the onset of attacks, 100% oxygen was administered through a facial mask at a rate of 7 liters per minute, for 15 minutes. Each patient self-treated ten attacks, and timed the rated reduction of pain. A successful treatment result required complete or almost complete reduction of pain in seven of ten attacks, within 15 minutes. In a second (crossover) trial involving an additional 50 patients, sublingual ergotamine tartrate (ErgomarÒ) was compared to oxygen inhalation for symptomatic relief of cluster attacks. Each patient treated ten attacks with either preparation in accordance with the crossover design. Oxygen was administered as described above. Sublingual ergotamine was used every five minutes, to a maximum of three tablets, if necessary. In the first trial 3952 (75%) of patients obtained significant relief from cluster pain. The greatest benefit (92.9%) was found among episodic patients under 50 years of age. The least benefit (57%), was found among chronic patients over 49 years of age. In the second trial, results among oxygen users were better (82%) than those of ergotamine users (70%), but not significantly. Rapidity of relief was similar in both groups. The results of both series indicate that oxygen inhalation is an efficacious symptomatic treatment for cluster attacks. It is superior to ergotamine since there are neither complications nor contraindications to its use. Ergotamine, however, has the advantage of convenience.

A post by Ted Marcus from the message board at CH.com about how he got his insurance company to approve oxygen therapy

When I was initially rejected by my insurance co for O2 I immediately called and spoke to my case manager at the insurance company (rather than waiting for them to send me paperwork and me send it back and them getting around to reading it and doing some sort of appeal without the benefit of my input or pushing things to get done. It's important to both be professional when talking to the case manager, but more important to charm them so they'll want to speed things up for you.) and she explained that when she talks to the company's doctor about my case she would need to show him abstracts (they have a lot of cases to go through and don't have time for reading many full articles on the subject) from reputable sources showing that O2 very well IS an effective treatment in aborting attacks. So I compiled a bunch of article summaries on the subject, faxed it to her and within a week of initial rejection had my oxygen once again. Here is what I sent:

Cephalalgia. 1995 Oct;15 Suppl 15:33-6.

Treatment of cluster headache: clinical trials, design and results.

Ekbom K

Department of Neurology, Soder Hospital, Stockholm, Sweden.

The spontaneous capricious course of cluster headache may give rise to some problems when treatment is being evaluated. This is one of several explanations for there being so few well-designed, randomized, double-blind clinical trials in cluster headache. The standard treatment of acute attacks of cluster headache is inhalation of 100% oxygen. In the prophylaxis of episodic cluster headache, ergotamine, verapamil, lithium, serotonin, inhibitors and steroids are used. In chronic cluster, lithium is the drug of choice, but verapamil may also be tried. Recently, hyperbaric oxygen has been shown to immediately abort acute attacks, and it seems that it may also be useful in the prophylactic treatment. The introduction of the novel 5HT1 agonist sumatriptan as a symptomatic relief of cluster attacks represents further significant progress. Two randomized, double-blind, placebo-controlled, cross-over trials have shown sumatriptan 6 mg sc to be a rapid, effective and well-tolerated acute treatment for cluster headache attacks. Within 15 min of treatment, 74% of attacks on sumatriptan responded compared to 26% of placebo-treated attacks. Functional disability was also significantly improved. Increasing the dose to 12 mg did not offer significantly greater relief compared to sumatriptan 6 mg, but was associated with an increased incidence of adverse events. Interim analysis of 3 months of data from a recent multinational open trial comprising, 138 patients having treated 6353 attacks with subcutaneous sumatriptan 6 mg revealed a headache relief in 96% of attacks treated. There was no evidence of an increased incidence of adverse events with frequent use of sumatriptan. No tachyphylaxis was seen over the 3 months, suggesting that sumatriptan is effective and well tolerated also in long-term acute treatment for cluster headache.

PMID: 8749244

J Pain Symptom Manage. 1993 Apr;8(3):155-64.

Diagnosis and treatment of cluster headache.

Campbell JK

Cluster headache (CH) is a rare form of headache occurring in both episodic and chronic forms. The painful attacks are short-lived, occur unilaterally, and are associated with signs and symptoms of autonomic involvement. Attacks frequently occur at night and can be precipitated by ingestion of alcohol. In the episodic form, attacks occur daily for some weeks followed by a period of remission. In the chronic form, attacks can continue for years. Inheritance is not a factor in CH. Treatment can be symptomatic or prophylactic. Agents used to treat individual attacks include inhalation of oxygen, rapidly acting forms of ergotamine and dihydroergotamine, and sumatriptan. Prophylactic treatment employs calcium-channel-blocking agents, methysergide, lithium, and corticosteroids. Surgical modalities, notably thermocoagulation of the gasserian ganglion, can provide relief in those who are resistant to medical management.

PMID: 8326166

Headache. 1996 Feb;36(2):105-7.

Analgesic use in cluster headache.

Gallagher RM, Mueller L, Ciervo CA

University Headache Center, University of Medicine & Dentistry of New Jersey,
Moorestown 08057, USA.

Cluster headache is a brutal affliction characterized by excruciating pain with relatively brief, but frequent attacks. Because of the short duration of the attacks and the tremendous intensity of pain, symptomatic analgesics are often not effective. However, inhalation oxygen, while being cumbersome, is reported to be effective in the majority of sufferers. To assess the practical effectiveness and use of analgesics and/or oxygen, a review of 60 cluster patients was conducted. At initial evaluation, 48 patients had accepted oral analgesics and 51 patients accepted inhalation oxygen for breakthrough headaches. After acceptable prophylactic treatment was established, 65% of patients who accepted analgesics continued their use, although most reported only minimal relief. Only 31% of patients who accepted oxygen continued its use, in spite of the fact that most sufferers reported significant relief. From this brief study, it appears that cluster headache patients prefer to use analgesics for reasons that are not solely for relief of pain, and that patients decline the use of oxygen for reasons other than lack of effectiveness.

PMID: 8742683