What is the treatment for cluster headaches?

Treatment of Cluster Headache

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

Acute Attack Management

First-line treatments:

• High-flow oxygen (100%):

  • Flow rate: 12-15 L/min
  • Duration: 15 minutes
  • Delivery: Non-rebreather mask
  • Efficacy: Pain-free in 78% of attacks within 15 minutes 2
  • Advantages: No medication overuse concerns, no daily limit on use

• Subcutaneous sumatriptan (6 mg):

  • Onset: Relief within 10-15 minutes
  • Efficacy: Effective in 49-74% of patients 1
  • Limitations: Not FDA-approved specifically for cluster headache 3
  • Caution: Maximum 2 doses/24 hours, separated by at least 2 hours

Second-line treatment:

• Intranasal zolmitriptan (10 mg):
  • Use when first-line treatments are unavailable or contraindicated 1

Preventive Treatment

First-line options:

1. Verapamil:

   • Starting dose: At least 240 mg daily
   • Monitoring: ECG before initiation and with dose increases
   • Caution: Requires cardiac monitoring 1, 4

2. Galcanezumab:

   • Indicated for episodic cluster headache only
   • Not effective for chronic cluster headache 1

Bridging therapy (until preventive medications take effect):

• Corticosteroids:
  • Dosage: At least 100 mg prednisone orally or up to 500 mg IV daily
  • Duration: 5 days 1, 4
  • Alternative: Greater occipital nerve blocks 4

Alternative preventive options:

• Non-invasive vagus nerve stimulation:

  • Effective for episodic cluster headache
  • Not effective for chronic cluster headache 1

• Other pharmacological options:

  • Lithium: Particularly effective for chronic cluster headache 4, 5
  • Topiramate: Alternative when first-line treatments fail 1, 5
  • Melatonin: May be effective in some patients 5, 6
  • Gabapentin: Possibly effective 6

Treatment Algorithm

1. For acute attacks:

   • Start high-flow oxygen immediately at attack onset
   • If unavailable or ineffective after 15 minutes, administer subcutaneous sumatriptan
   • For patients with contraindications to both, use intranasal zolmitriptan

2. For prevention:

   • Episodic cluster headache: Start with verapamil or galcanezumab
   • Chronic cluster headache: Start with verapamil or lithium
   • Use corticosteroids as bridging therapy while waiting for preventives to take effect
   • Consider non-invasive vagus nerve stimulation for episodic cluster headache

Important Considerations

• Avoid using opioids for cluster headache as they can lead to dependency and rebound headaches 7
• Patients should begin treatment immediately at attack onset for maximum effectiveness 1
• Arrange home oxygen with provision for urgent 4-hour installation when a cluster period begins 1
• Monitor cardiac function in patients using verapamil with ECG before initiation and with dose increases 1
• Educate patients to avoid known triggers, particularly alcohol 1
• Evaluate treatment efficacy regularly to adjust therapy as needed

Common Pitfalls to Avoid

• Delayed treatment: Efficacy decreases when treatment is delayed after attack onset
• Inadequate oxygen flow rate: Using less than 12 L/min reduces effectiveness
• Medication overuse: Limit use of triptans to avoid medication overuse headache
• Inappropriate preventive selection: Using galcanezumab for chronic cluster headache
• Insufficient monitoring: Failing to monitor cardiac function with verapamil therapy
• Prolonged steroid use: Extending corticosteroid use beyond recommended duration increases side effect risk