Oxygen for Cluster-Dr. Tepper
Migraine Volume 57; Issue 9, October, 2017 pages 1493+1494
Oxygen for Cluster Headache
Deborah Tepper MD
Cluster headache is the most severe of the primary headache disorders, with attacks occurring up to eight times per day lasting between 15 minutes to 3 hours. The attacks are accompanied by restlessness, anxiety, and agitation, and unlike migraine, the pain is so intense that the individual does not want to lie down and remain still.
Because of the speed at which a cluster attack reaches peak, and the frequency and severity of attacks, a pill to relieve cluster will usually not work fast enough to stop the headache. Injections of sumatriptan or nasal triptans become expensive given how many headache attacks cluster sufferers get per day, and are not recommended to be used more than twice per day.
High flow oxygen is a safe, rapid, and usually highly effective treatment to stop a cluster headache attack. It needs to be administered with a special mask, called a non-rebreather mask that keeps the oxygen flowing in, but does not allow carbon dioxide to build up. Oxygen treatment is frequently effective in less than 10 minutes, and carries with it no increased risk of heart attack or stroke. This safety profile is especially important because many individuals with cluster headaches are long time users of cigarettes.
Effective use of oxygen for cluster is given at a speed, called a flow rate, between 6 and 15 liters per minute, much higher than typical oxygen given to patients for other disorders. At this flow rate, using a tube going to the nose, called a nasal cannula, will not work. That is why the non-rebreather mask, which does not permit the oxygen to escape and does not allow buildup of the exhaled carbon dioxide, is necessary.
If oxygen is so safe and effective, why is it not more widely available to those who suffer from this agonizing headache disorder? One reason is that sometimes prescriptions are rejected by insurers. Another is that prescribers do not know how these prescriptions should be written. Many patients and their physician assume that oxygen, administered at this rate, and requiring tanks delivered to the home, will be too expensive, and will instead prescribe triptan injections or nasal sprays for the attacks. The cost of oxygen does depend on insurance reimbursement, which can vary. After insurance, costs to patients who have cluster headaches in cycles, with time off, called episodic cluster, are actually less than $1,000 per year for most patients. For those who have chronic cluster headaches, that is cluster cycles that continue without a month of let up in a year, the annual cost will be higher, between $2,000 and $5,000 per year depending on the insurance.
Insurance companies may not cover oxygen usage for cluster headaches, and about 35% of insurance companies will reject the claim. This may come from a lack of understanding about cluster headaches, and a mistaken belief that it is more expensive to allow oxygen for cluster attacks than to cover triptan injections or nasal sprays multiple times per day. If an insurance company will not pay, or the patient lacks insurance coverage, the cost of oxygen is different according to the state. For a chronic cluster patient who has to pay out of pocket, oxygen may cost a wide range of prices depending on where the patient lives, from less than $500 to more than $10,000 per year in a few states.
The US government Center for Medicare and Medicaid Services ruled that they will not cover oxygen for cluster headache, despite the strong evidence of oxygen benefit and the fact that oxygen is the standard of care for acute treatment of cluster headache attacks, both in the US and worldwide. This means if a patient has Medicare or Medicaid insurance, oxygen will not be paid for by that insurance. Patients may purchase the oxygen themselves with a prescription brought to the oxygen supplier if it is not covered, and in many states, as noted, the oxygen is affordable.
Patients who lack insurance coverage for oxygen will sometimes purchase non-medical grade oxygen, sometimes called welder's oxygen. In general, both medical and non-medical grade oxygen have 99% oxygen in the tank. However, non-medical oxygen is not filled using a vacuum that would remove any trace impurities in the tank of gas. The price difference between medical and non-medical oxygen is small, around $4 per tank, so it is usually not worthwhile to pursue this savings.
The prescription needs to be precise and include oxygen, a non-rebreather mask, a regulator (the control measuring the release of oxygen necessary because the flow rate is so high), the tank, and a wheeled cart for transport. The largest portable tank is an E-tank. An E-tank empty weighs about 8 pounds and holds 680 liters. Depending on the insurance and oxygen supply company preferences, the tank may be rented monthly and refilled as needed, or bought and refilled as needed or monthly. For some, there is no upfront cost for rent or refill. The masks and regulators may be included, rented, or purchased separately.
For those who have cluster headaches, oxygen is a safe, economical treatment to use without concern for overuse, serious side effects, or long-term harm. It is effective, and needs to be an available option for all patients with cluster headaches. Discuss the prescription with your healthcare provider. Remind your provider that the prescription needs to include a large portable E-tank, and a non-rebreather mask with a regulator such that the oxygen flow can be adjusted up to 15 liters. Insurers may be referred to the American Headache Society Guidelines for Cluster Headaches to be informed that this essential treatment for cluster headache is the current standard of care.
· Deborah Tepper, MD
· Harvard Beth Israel Deaconess Sandwich
· Boston, MA, USA