Internal Medicine

0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54

Cluster Headache Coccidioides Immitis 363

management

■General measures: avoid alcohol, vasodilators, smoking

specific therapy

■Agents to abort an individual headache

➣Oxygen by face mask 7–10 L/min for 15 minutes

➣5-HT agonists: sumatriptan, rizatriptan, zolmitriptan, naratrip-

tan, almotriptan, eletriptan, frovatriptan

➣DHE, intranasal lidocaine (2% gel) occasionally effective

■Prophylactic agents

➣DHE IM or SC in divided doses

➣Prednisone (episodic cluster) for 3–5 d followed by taper over

1wk

➣Verapamil SR (episodic cluster)

➣Methysergide (episodic cluster) (may be used qhs for nocturnal

attacks)

➣Valproic acid (chronic cluster)

➣Lithium (chronic cluster); must monitor serum level, keep <1.2

mEq/L

follow-up

■Indicated if attacks are frequent or ongoing prophylactic therapy

complications and prognosis

■Prognosis good

Coccidioides Immitis.................................

RICHARD A. JACOBS, MD, PhD

history & physical

History

■Endemic to soils of certain regions of Western Hemisphere

■In United States, endemic in desert Southwest (portions of

California, esp San Joaquin Valley, southern Nevada, Arizona, New

Mexico, western Texas, southwest Utah)

■Other areas: Mexico, Central America, South America

■Most easily recovered at end of winter rains, but new infections peak

during summer months with dry soil

■Rate of infection in endemic area: 3%/year