The use of oxygen in cluster headache treatment worldwide – a survey of the International Headache Society (IHS)

Breathing 100% oxygen is recommended for the treatment of acute attacks of cluster headache. This treatment is evidence based (1,2) and part of many treatment guidelines worldwide (3,4). However, in many countries there is uncertainty whether this treatment is covered by health insurances; furthermore many countries do not have national treatment guidelines for cluster headache.

Therefore, the Board of the International Headache Society (IHS) decided in 2015 to perform and publish a survey from their national membership societies on the use of and on the legal situation and the national and private health insurance position on oxygen for the treatment of an acute attack of cluster headache. In total, 53 societies received an email questionnaire covering several questions about reimbursement and real use (in particular with respect to age), and were asked to make any specific comments they wanted. Twenty-two societies filled in the questionnaire (42%) (Europe = 15; Asia = 6; The Americas = 1); all questionnaires were able to be used for the analysis. The most important answers are listed in Table 1.

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Table 1.

Answers from all countries responding to the questionnaire.

Country	Oxygen reimbursed?	Device reimbursed?	Age restrictions?
Austria	No	No	No
Canada	Yes	Yes	No
China (PR)	Yes	Yes	No
Estonia	No	No	No
France	Yes	Yes	No
Germany	Yes	Yes	No
Hungary	Yes	Yes	No
Italy	No	No	No
Japan	No	No	No
Korea (South)	Yes	No	Yes
Moldovia	No	No	No
The Netherlands	Yes	Yes	No
Norway	Yes	Yes	Yes
Philippines	No	No	No
Portugal	Yes	Yes	No
Romania	No	No	No
Serbia	No	No	Yes
Slovakia	No	No	(No answer)
Switzerland	No	Yes	No
Taiwan	Yes	No	No
Turkey	No	No	No
United Kingdom	Yes	Yes	Yes

Oxygen for cluster headache attack treatment is reimbursed by the national public or private health insurance companies in exactly 50% of all countries responding. In two countries, the facial mask, but not oxygen itself, is reimbursed; whereas in one country only the oxygen but not the facial mask is reimbursed. This means that oxygen and all equipment for its use in cluster headache attack treatment are fully reimbursed in only 41% of responding countries. For those patients over the age of 65, oxygen for cluster headache attacks is also reimbursed when it is reimbursed for younger patients, with one exception. Two additional countries provide reimbursement for the use of oxygen in general for patients over the age of 65. In only three countries (14%), there are medical restrictions (or restrictions by the authorities) for the use of oxygen in patients over the age of 65. In the United States, oxygen for cluster headache is not reimbursed by the federal government for those over 65 (Medicare patients) and those on financial assistance from individual states funded by the federal government (Medicaid or Title 19).

In the comments, some membership societies gave more detailed information. In one country, only the private health insurers (covering 10% of the population) reimburse patients for oxygen. Another country reported restrictions for the first use of oxygen because it is normally not provided in outpatient clinics. Some countries gave specific recommendations for the appropriate use of oxygen in cluster headache attack treatment (i.e. 100% concentration; full facial mask; rebreathing mask). In one country only a nasal canula and not a full facial mask is reimbursed. One national membership society provided an example of how to write a prescription for oxygen and any necessary device including a facial mask.

Some national societies unofficially recommend prescribing oxygen only for respiratory insufficiency or hypoxaemia and not cluster headache. In one country, reimbursement of oxygen for cluster headache is possible only if the positive effect of using the oxygen has been confirmed by a physician.

In summary, in only about 40% of the responding national societies around the world is there unrestricted access to oxygen for the initial treatment for the acute attacks of cluster headache. In many situations, there is no reimbursement, which means that poorer patients cannot afford this safe treatment. There may be even less reimbursement in the countries we did not hear from. Countries from South America, Africa and Southern Asia did not respond.

In some countries, additional medical restrictions for the patients over the age of 65 are present, but this is not a common limitation. It should be noted that most headache specialists agree that appropriate use of oxygen requires 7 to 15 litres of 100% oxygen to be delivered by facial mask, but in some countries only other parameters are approved.

Based on this survey, we believe that the following recommendations could influence the reimbursement system and, thus, increase the appropriate use of oxygen in cluster headache patients worldwide:

‐ Provide national treatment guidelines on cluster headache.