What are the treatment options for cluster headaches?

Treatment Options for Cluster Headaches

High-flow oxygen therapy (12-15 L/min via a non-rebreather mask) should be offered as first-line treatment for acute attacks of cluster headache, followed by subcutaneous sumatriptan if oxygen is ineffective or unavailable. 1

Acute Treatment Options

First-Line Treatments

1. High-flow oxygen therapy

   • 100% oxygen at 12-15 L/min via a non-rebreather mask 1, 2
   • Continue for at least 15 minutes at the onset of an attack 2
   • Effective in 78% of patients within 15 minutes (vs. 20% with placebo) 2
   • No significant adverse events reported 2
   • Patients should be provided with appropriate equipment to ensure delivery of high flow rate oxygen 1

2. Subcutaneous sumatriptan

   • 6 mg subcutaneous injection 1, 3
   • Provides relief within 10-15 minutes in 49-74% of patients 3
   • FDA-approved specifically for cluster headache treatment 3

Second-Line Treatments

1. Intranasal zolmitriptan
   • 10 mg intranasal formulation 1
   • Less rapid onset than subcutaneous sumatriptan but still effective 1

Preventive Treatment Options

For Episodic Cluster Headache

1. Galcanezumab

   • Recommended for prevention of episodic cluster headache 1, 4
   • Not recommended for chronic cluster headache 1

2. Noninvasive vagus nerve stimulation

   • Recommended for prevention of episodic cluster headache 1, 4
   • Not effective for chronic cluster headache 5

3. Verapamil

   • Daily dose of at least 240 mg 5
   • Insufficient evidence for a strong recommendation, but widely used in practice 1

4. Corticosteroids (short-term bridging therapy)

   • At least 100 mg prednisone orally or up to 500 mg IV daily for 5 days 5
   • Used as bridging therapy until preventive medications take effect

Alternative Preventive Options

1. Greater occipital nerve blocks 5
2. Lithium and topiramate 5

Implementation Considerations

• For patients with episodic cluster headache, home oxygen should be arranged with provision for urgent 4-hour installation when a cluster period begins 1
• Patients typically have warning of a cluster headache attack, allowing time to prepare oxygen therapy 1
• Oxygen concentrators can be an effective alternative to oxygen tanks, with studies showing they provide similar efficacy 6
• Patients should be educated to begin treatment immediately at the onset of an attack for maximum effectiveness 4

Treatment Algorithm

1. For acute attacks:

   • Start with high-flow oxygen (12-15 L/min) via non-rebreather mask for 15 minutes
   • If oxygen is unavailable or ineffective, use subcutaneous sumatriptan 6 mg
   • For patients who cannot use subcutaneous injections, consider intranasal zolmitriptan 10 mg

2. For prevention during cluster periods:

   • Initiate galcanezumab for episodic cluster headache
   • Consider verapamil (≥240 mg daily) with appropriate cardiac monitoring
   • Use corticosteroids as bridging therapy until preventive medications take effect

3. For patients with inadequate response:

   • Consider noninvasive vagus nerve stimulation for episodic cluster headache
   • Evaluate for greater occipital nerve blocks
   • Consider alternative preventives like lithium or topiramate

Important Considerations

• Avoid implantable sphenopalatine ganglion stimulators, as they are not recommended 1
• Galcanezumab should not be used for chronic cluster headache 1
• Electrical stimulation of the greater occipital nerve is not recommended due to side effect profile 5
• Patients should be counseled to avoid known triggers, particularly alcohol 4

High-flow oxygen therapy remains the safest and most effective first-line treatment for acute cluster headache attacks, with subcutaneous sumatriptan providing an effective alternative when oxygen is unavailable or ineffective.