58,59 In an open-label study, 23 ECH and 31 CCH patients were admitted to the hospital for treatment with repetitive intravenous DHE.60 All patients became headache free while being treated with IV DHE: 10 patients MLN0128 manufacturer (16%) after the first dose, an additional 12 (19%) during the first day of hospitalization,

and 22 (34%) more became headache free by the second day of hospitalization. By day 3, greater than 90% of patients were headache free and by day 5 all were headache free. At 3 months after discharge, >90% of ECH patients and 44% of CCH patients remained headache free. Approximately 83% of patients reported no AEs from IV DHE. Reported AEs included nausea, non-cardiac chest tightness, and a metallic taste. Ergotamine tartrate, 3-4 mg per day in divided doses, may be administered for 2 to 3 weeks for transitional prophylaxis.58,61 Administration just before bedtime may help to prevent nighttime attacks. With an individually

tailored pharmacologic treatment plan, the majority of CH patients will achieve satisfactory results. For those who remain refractory to medical treatment, a number of invasive procedures are available. These include peripheral nerve blocks, peripheral or central neurostimulation and, as a last resort, ablative selleck inhibitor surgery. Peripheral nerve block, mostly targeting the greater occipital nerve (GON), may also be used in less refractory patients, as an adjunct to pharmacologic therapy. Efficacy

of GON block in CH treatment was suggested by Anthony in the 1980s.62 More recently, the procedure was investigated as CH treatment in a number of studies, with the majority showing positive results.63-66 Peres et al evaluated the effect of GON block in 14 patients with CH.63 Patients received GON block ipsilateral to the head pain using lidocaine 1% and triamcinolone 40 mg. Patients were evaluated before and 1 week after the block. Nine (64%) patients had good or moderate response. The procedure was well tolerated. Ambrosini et al evaluated the effect of suboccipital injection of lidocaine 2% with betamethasone, compared with lidocaine and saline, in 23 CH patients in a randomized, controlled study.64 The CH attacks disappeared within 72 hours in 85% of medchemexpress the lidocaine + betamethasone group (with 61% remaining attack free for 4 weeks) compared with none in the lidocaine + saline group. Injections were well tolerated. Afridi et al examined the efficacy of GON block, using lidocaine 2% and methylprednisolone, in patients with refractory chronic daily headache.65 Their sample included 19 patients with CH who received 22 injections. Thirteen of the injections (59%) resulted in a complete or partial response, with a median duration of 12 and 21 days, for complete and partial response, respectively.