What are the treatment options for cluster headaches?

Treatment Options for Cluster Headache

For cluster headaches, high-flow oxygen therapy (12-15 L/min via a non-rebreather mask) is recommended as first-line treatment for acute attacks, followed by subcutaneous sumatriptan (6 mg) if oxygen is ineffective or unavailable. 1, 2

Acute Treatment Options

First-Line Treatments

• High-flow oxygen therapy:

  • Flow rate: 12-15 L/min via a non-rebreather mask 1, 3
  • Duration: 15 minutes at the start of an attack 3
  • Efficacy: Pain relief in 78% of patients within 15 minutes 3
  • Practical consideration: Home oxygen concentrators can be an effective alternative to oxygen tanks with similar efficacy 4

• Subcutaneous sumatriptan:

  • Dosage: 6 mg 2, 5
  • Efficacy: Provides relief within 10-15 minutes in 49-74% of patients 5
  • FDA-approved specifically for cluster headache 5
  • Clinical trial data shows significant pain relief at 10 minutes (49%) and 15 minutes (74-75%) post-injection 5

Second-Line Treatment

• Intranasal zolmitriptan:
  • Dosage: 10 mg 2, 1
  • Less rapid onset than subcutaneous sumatriptan but still effective 1
  • Recommended when first-line treatments are unavailable or contraindicated 2

Preventive Treatment Options

First-Line Preventive Therapy

• Galcanezumab:
  • Recommended for prevention of episodic cluster headache 2, 1
  • Not recommended for chronic cluster headache 2, 1

Additional Preventive Options

• Verapamil:

  • Daily dose of at least 240 mg 1, 6
  • Widely used in practice despite insufficient evidence for a strong recommendation 1
  • Requires appropriate cardiac monitoring 1

• Corticosteroids (short-term bridging therapy):

  • Used until preventive medications take effect 1, 6
  • Dosage: At least 100 mg prednisone orally or up to 500 mg IV daily for 5 days 1, 6

• Non-invasive vagus nerve stimulation:

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

• Alternative preventive options (when first-line treatments fail):

  • Lithium 6, 7
  • Topiramate 6, 7
  • Greater occipital nerve blocks 1, 6

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
   • If both are contraindicated, consider intranasal zolmitriptan 10 mg

2. For prevention during cluster periods:

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

3. For inadequate response:

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

Important Clinical Considerations

• Patients should begin treatment immediately at the onset of an attack for maximum effectiveness 1
• Patients with episodic cluster headache should have home oxygen arranged with provision for urgent installation when a cluster period begins 1
• Avoid alcohol during cluster periods as it is a common trigger 1
• Galcanezumab should not be used for chronic cluster headache 2, 1
• Patients should be educated about the importance of having rescue medication readily available during cluster periods 1

Monitoring and Follow-up

• Monitor cardiac function in patients using verapamil (ECG before initiation and with dose increases)
• Evaluate treatment efficacy regularly and adjust therapy as needed
• Consider transitioning from bridging therapy to long-term preventive treatment as appropriate