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Intranasal sumatriptan in cluster headache

Randomized placebo-controlled double-blind study

From the Department of Neurology (Drs. van Vliet and Ferrari), Leiden University Medical Centre, the Netherlands; Headache Group (Drs. Bahra and Goadsby), Institute of Neurology, Queen Square, London, UK; Cincinnati Headache Center (Drs. Martin and Ramadan), OH; Headache Center (Dr. Aurora), Seattle, WA; and Houston Headache Clinic (Dr. Mathew), Houston, TX.

Address correspondence and reprint requests to Prof. Peter J. Goadsby, Institute of Neurology, Queen Square, London, WC1N 3BG UK; e-mail: peterg{at}ion.ucl.ac.uk

Background: Current evidence-based acute treatments of cluster headache are limited to oxygen inhalation and subcutaneous sumatriptan. Intranasal sumatriptan is a new formulation with better tolerability than the subcutaneous route. Two open-label studies suggested efficacy of intranasal sumatriptan in cluster headache.

Methods: In a double-blind placebo-controlled randomized trial, patients with episodic or chronic cluster headache whose attacks lasted at least 45 minutes each treated one attack with 20 mg sumatriptan nasal spray and another one, at least 24 hours later, with matching placebo. They scored their headache on a five-point scale (very severe, severe, moderate, mild, or none) at 5, 10, 15, 20, and 30 minutes. The primary outcome measure was headache response (a decrease in pain from very severe, severe, or moderate to mild or none) at 30 minutes. Secondary outcome measures included pain-free rates, relief of associated symptoms, and rates of adverse events. Multilevel multivariate analysis was used for statistical analysis.

Results: Five study centers enrolled 118 patients in whom 154 attacks were treated: 77 with sumatriptan and 77 with placebo. The responder rates at 30 minutes were 57% for sumatriptan and 26% for placebo (p = 0.002). Pain-free rates at 30 minutes were 47% for sumatriptan and 18% for placebo (p = 0.003). Sumatriptan was also superior to placebo considering initial response, meaningful relief, and relief of associated symptoms. There were no serious adverse events.

Conclusion: Sumatriptan nasal spray is effective and well tolerated in the acute treatment of cluster headache attacks of at least 45 minutes’ duration.

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