From the Guidelines
Cluster headaches are severe, one-sided headaches characterized by excruciating pain around one eye, accompanied by autonomic symptoms like tearing, nasal congestion, and eyelid drooping, and should be managed with acute treatments such as subcutaneous sumatriptan (6 mg) or intranasal zolmitriptan (10 mg), and preventive strategies like galcanezumab for episodic cluster headache. These headaches typically last 15-180 minutes, occur in cyclical patterns or clusters lasting weeks to months, followed by remission periods. Management involves both acute treatment and preventive strategies. For acute attacks,
- high-flow oxygen (12-15 L/min via non-rebreather mask) is highly effective and should be administered promptly, as supported by the British Thoracic Society guidelines 1
- injectable or nasal sumatriptan can abort attacks within minutes, as suggested by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1
- normobaric oxygen therapy is also suggested for the short-term treatment of cluster headache 1. For prevention during cluster periods,
- galcanezumab is suggested for the prevention of episodic cluster headache, as recommended by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1
- verapamil's effectiveness for prevention is uncertain, with insufficient evidence to recommend for or against its use for episodic or chronic cluster headache 1. Lifestyle management includes avoiding alcohol during cluster periods, maintaining regular sleep patterns, and avoiding high altitudes. Neuromodulation techniques like vagus nerve stimulation or sphenopalatine ganglion stimulation may benefit refractory cases. The pathophysiology involves hypothalamic dysfunction and trigeminal-autonomic activation, explaining both the clockwork timing and the distinctive pain and autonomic features of these headaches.
From the FDA Drug Label
Cluster Headache The efficacy of IMITREX Injection in the acute treatment of cluster headache was demonstrated in 2 randomized, double-blind, placebo-controlled, 2-period crossover trials. Patients age 21 to 65 were enrolled and were instructed to treat a moderate to very severe headache within 10 minutes of onset Headache relief was defined as a reduction in headache severity to mild or no pain. In both trials, the proportion of individuals gaining relief at 10 or 15 minutes was significantly greater among patients receiving 6 mg of IMITREX Injection compared with those who received placebo
The key features of cluster headaches include:
- Moderate to very severe headache
- Rapid onset of relief with treatment, as evidenced by a reduction in headache severity to mild or no pain
- Time to relief: 10 or 15 minutes after injection of sumatriptan
- Response to treatment: significantly greater proportion of individuals gaining relief with sumatriptan compared to placebo 2 2 The management of cluster headaches involves:
- Acute treatment: sumatriptan injection, which has been shown to be effective in reducing headache severity
- Dosing: 6 mg of sumatriptan injection, which has been demonstrated to be effective in clinical trials
- Administration: injection within 10 minutes of headache onset, with the option for a second injection if needed after 1 hour 2 2
From the Research
Characteristics of Cluster Headaches
- Cluster headaches are characterized by attacks of severe, strictly unilateral pain that is orbital, supraorbital, temporal, or any combination of these, lasting 15-180 min, and occurring from once every other day to eight times a day 3, 4, 5.
- The pain is associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis and/or eyelid edema, and/or with restlessness or agitation 3, 4, 5.
- Cluster headache is considered to be a neurovascular and chronobiologic headache disorder, with a pivotal role played by the central brain mechanisms 3.
Management of Cluster Headaches
- The main focus of therapy is to abort attacks once they have begun and to prevent future attacks 3.
- Fast-acting abortive treatment, transitional treatment, and preventive treatment are used to manage cluster headaches 4.
- Subcutaneous sumatriptan and high-flow oxygen are the most proven abortive treatments for cluster headache attacks 4, 5, 6, 7.
- Verapamil and lithium are the preventive drugs of first choice and the most widely used in first-line preventive treatment 4, 5, 6, 7.
- Transitional treatment, such as corticosteroids or greater occipital nerve blockade, can be given at the start of a cluster 5, 6, 7.
- Neuromodulation, such as occipital nerve stimulation or deep brain stimulation of the hypothalamus, is an alternative treatment strategy for drug-resistant cluster headaches 5, 6.