Is hyperbaric oxygen therapy (HBOT) effective for treating headaches?

Hyperbaric Oxygen Therapy for Headache Treatment

Hyperbaric oxygen therapy (HBOT) is not recommended as a routine treatment for most headache types, with the exception of cluster headaches where normobaric oxygen therapy may be beneficial.

Efficacy of HBOT for Different Headache Types

Migraine Headache

• There is insufficient evidence to recommend HBOT for the treatment or prevention of migraine headaches 1
• The 2023 VA/DoD Clinical Practice Guideline for Headache Management does not include HBOT among recommended treatments for migraine 1
• While some small studies have suggested potential benefit, the quality of evidence is low and does not support routine clinical use 2
• Standard first-line treatments for migraine include acetaminophen, aspirin, ibuprofen, or naproxen for acute treatment 1

Cluster Headache

• Normobaric oxygen therapy (not hyperbaric) is recommended for the short-term treatment of cluster headache 1
• The VA/DoD guidelines specifically suggest normobaric oxygen therapy as a "weak for" recommendation in cluster headache treatment 1
• Normobaric oxygen has shown effectiveness in terminating cluster headache attacks in approximately 75% of cases 2
• Other recommended treatments for cluster headache include subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg) 1

Tension-Type Headache

• No evidence supports HBOT for tension-type headaches 1
• Standard treatments include ibuprofen (400 mg) or acetaminophen (1000 mg) for acute treatment 1
• Amitriptyline is suggested for prevention of chronic tension-type headache 1

Evidence Quality and Limitations

• Most studies on HBOT for headache are small, with poor to moderate methodological quality 2
• A Cochrane systematic review found limited evidence for HBOT in migraine relief compared to sham therapy, but noted the studies were small with incomplete reporting 2
• The practical limitations of HBOT include:
  • High cost and poor availability 2
  • Need for specialized equipment and trained personnel 1
  • Potential side effects including barotrauma, claustrophobia, and rarely seizures 1

Clinical Application and Considerations

• For cluster headaches, normobaric oxygen (100% oxygen at normal atmospheric pressure) is more practical, cost-effective, and has better evidence than HBOT 1, 2
• HBOT requires administration in a specialized pressurized chamber, making it impractical for acute headache treatment 1
• Case reports suggest potential benefit in treatment-resistant migraine cases, but this is not supported by high-quality evidence 3

Common Pitfalls and Caveats

• Don't confuse normobaric oxygen therapy (recommended for cluster headache) with hyperbaric oxygen therapy (insufficient evidence) 1, 2
• The cost and limited availability of HBOT make it impractical as a first-line therapy for headache disorders 2
• While some patients may report benefit from HBOT for migraines, this could represent placebo effect rather than true efficacy 4
• HBOT should not delay the use of evidence-based treatments for headache disorders 1

Algorithm for Headache Treatment

1. For cluster headache:

   • First-line: Normobaric oxygen therapy (not hyperbaric) 1
   • Alternative: Subcutaneous sumatriptan or intranasal zolmitriptan 1

2. For migraine:

   • First-line: Acetaminophen, aspirin, ibuprofen, or naproxen 1
   • Second-line: Rimegepant or ubrogepant 1
   • HBOT not recommended based on current evidence 2

3. For tension-type headache:

   • Acute treatment: Ibuprofen or acetaminophen 1
   • Prevention (chronic): Amitriptyline 1
   • HBOT not recommended 1