What is the recommended treatment for cluster headaches?

Treatment of Cluster Headache

For the acute treatment of cluster headache attacks, high-flow oxygen therapy (12-15 L/min via a non-rebreather mask for 15 minutes) and subcutaneous sumatriptan (6 mg) are the recommended first-line treatments. 1, 2

Acute Treatment Algorithm

1. First-line options:

   • High-flow oxygen therapy (100%) at 12-15 L/min via a non-rebreather mask for 15 minutes 2, 3

     • Provides relief in 78% of patients within 15 minutes 4
     • Advantages: no side effects, no contraindications, can be used multiple times daily
     • Disadvantages: less portable, potential "rebound effect" 5

   • Subcutaneous sumatriptan (6 mg) 1, 2, 6

     • Provides relief within 10-15 minutes in 49-74% of patients 2
     • Clinical trials show 70% of patients achieve headache relief within 1 hour 6
     • Contraindicated in patients with cardiovascular disease 2

2. Second-line option:

   • Intranasal zolmitriptan (10 mg) when first-line treatments are unavailable or contraindicated 1, 2

Preventive Treatment Algorithm

1. First-line preventive therapy:

   • Galcanezumab for episodic cluster headache (NOT for chronic cluster headache) 1, 2, 7

   • Verapamil (minimum 240 mg daily) 2, 7, 8

     • Requires cardiac monitoring (ECG before initiation and with dose increases) 2
     • Dose may be increased based on efficacy and tolerability 7

2. Bridging therapy (while waiting for preventive medications to take effect):

   • Corticosteroids (short-term use) 2, 7

     • At least 100 mg prednisone orally or up to 500 mg IV daily for 5 days 2, 7

   • Greater occipital nerve blocks 2, 7

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

   • Non-invasive vagus nerve stimulation for episodic cluster headache (not effective for chronic cluster headache) 1, 2, 7
   • Lithium 2, 7, 8
   • Topiramate 2, 7, 8
   • Melatonin (possibly effective) 8

Important Clinical Considerations

• Avoid opioids for cluster headache as they can lead to dependency and rebound headaches 2

• Timing is critical - patients should begin treatment immediately at the onset of an attack for maximum effectiveness 2

• Home oxygen arrangements should include provision for urgent 4-hour installation when a cluster period begins 2

• Regular monitoring of treatment efficacy is necessary to adjust therapy as needed 2

• Implantable sphenopalatine ganglion stimulator is not recommended for cluster headache treatment 1

Treatment Efficacy

• Subcutaneous sumatriptan provides headache relief in 70% of patients within 1 hour and 82% within 2 hours 6

• High-flow oxygen provides pain freedom in 78% of patients within 15 minutes compared to only 20% with placebo 4

• The efficacy of sumatriptan is unaffected by whether the cluster headache is associated with aura, duration of attack, gender, or age 6

• Non-invasive vagus nerve stimulation has moderate evidence supporting its use in episodic cluster headache but is not effective for chronic cluster headache 2

By following this treatment algorithm and considering these important clinical factors, providers can effectively manage both acute attacks and provide preventive therapy for patients with cluster headache, significantly improving their quality of life and reducing disability.