What is the recommended treatment for cluster headaches?

Treatment of Cluster Headaches

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

Acute Treatment Options

First-Line Treatments

1. High-flow oxygen therapy

   • Flow rate: 12-15 L/min
   • Duration: 15 minutes
   • Delivery: Non-rebreather mask
   • Efficacy: Pain freedom in 78% of patients within 15 minutes 2
   • Advantages: No side effects, no contraindications, can be used multiple times daily 3
   • Practical considerations: Home oxygen concentrators can be an effective alternative to oxygen tanks 4

2. Subcutaneous sumatriptan (6 mg)

   • Efficacy: 49-74% of patients achieve relief within 10-15 minutes, 70% within 1 hour 1, 5
   • FDA-approved specifically for cluster headache 5
   • Can be used for prolonged periods without loss of efficacy or safety 3
   • Contraindications: Cardiac, cerebral, or peripheral vascular disease 3

Second-Line Treatment

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

Treatments to Avoid

• Opioids should be avoided due to risk of dependency and rebound headaches 1

Preventive Treatment

First-Line Preventive Therapies

1. Galcanezumab

   • Recommended for episodic cluster headache only (not effective for chronic cluster headache) 1

2. Verapamil

   • Dosage: At least 240 mg daily
   • Requires cardiac monitoring (ECG before initiation and with dose increases) 1, 6

3. Corticosteroids (short-term bridging therapy)

   • Dosage: At least 100 mg prednisone orally or up to 500 mg IV daily for 5 days 1, 6
   • Purpose: Provides relief until longer-acting preventive medications take effect

Alternative Preventive Options

1. Non-invasive vagus nerve stimulation

   • Effective for episodic cluster headache but not for chronic cluster headache 1

2. Other options when first-line treatments fail

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

Patient Education and Management Pearls

• Begin preventive treatment immediately at the onset of a cluster period
• Arrange for home oxygen with provision for urgent 4-hour installation when a cluster period begins 1
• Educate patients to begin acute treatment immediately at attack onset for maximum effectiveness
• Counsel patients to avoid known triggers, particularly alcohol 1
• Regular evaluation of treatment efficacy is necessary to adjust therapy

Common Pitfalls to Avoid

1. Delayed treatment initiation

   • Acute treatment should begin immediately at the onset of an attack
   • Preventive treatment should begin at the start of a cluster period

2. Inadequate oxygen flow rate

   • Using less than 12 L/min reduces effectiveness
   • Using a simple face mask instead of a non-rebreather mask

3. Insufficient monitoring with verapamil

   • ECG monitoring is essential before initiation and with dose increases

4. Using galcanezumab for chronic cluster headache

   • Only effective for episodic cluster headache

5. Relying on opioids

   • Can lead to dependency and rebound headaches
   • Not effective for cluster headache management

The European Academy of Neurology guidelines strongly support the use of high-flow oxygen and subcutaneous sumatriptan as first-line acute treatments, with verapamil as the primary preventive therapy 6. This approach prioritizes treatments with the strongest evidence for reducing the severe pain and disability associated with cluster headaches.