What are the medications for cluster headaches?

Medications for Cluster Headaches

For cluster headaches, first-line abortive treatments are subcutaneous sumatriptan (6 mg), intranasal zolmitriptan (10 mg), and high-flow oxygen therapy (12-15 L/min via non-rebreather mask for 15 minutes). 1, 2

Abortive Treatments

First-Line Options:

1. Subcutaneous Sumatriptan (6 mg)

   • Provides relief within 10-15 minutes in 49-74% of patients 2
   • Clinical trials show 74-75% of patients achieve relief within 15 minutes 3, 4
   • Contraindicated in patients with:
     • Ischemic heart disease
     • Previous myocardial infarction
     • Prinzmetal's angina
     • Uncontrolled hypertension 3, 5

2. Intranasal Zolmitriptan (10 mg)

   • Achieves 62% pain relief at 30 minutes compared to 26% with placebo (NNT 2.8) 4
   • Second-line option when sumatriptan is contraindicated 2

3. High-flow Oxygen Therapy

   • 12-15 L/min via non-rebreather mask for 15 minutes 2
   • Advantages: free from side effects, no contraindications, can be used multiple times daily 6
   • Can be used in patients with cardiovascular conditions where triptans are contraindicated 6
   • Consider arranging home oxygen with provision for urgent 4-hour installation when a cluster period begins 2

Preventive Treatments

First-Line Options:

1. Galcanezumab

   • Recommended for episodic cluster headache 1, 2
   • Not recommended for chronic cluster headache 1, 2

2. Verapamil

   • Commonly used preventive treatment (at least 240 mg daily) 2, 7
   • Requires cardiac monitoring with ECG before initiation and with dose increases 2
   • Evidence is insufficient for a strong recommendation 1

Bridge Therapy (Short-term Prevention):

1. Corticosteroids

   • Used as short-term bridging therapy until preventive medications take effect 2, 7
   • Typically 100 mg prednisone orally or up to 500 mg IV daily for 5 days 2

2. Greater Occipital Nerve Blocks

   • Alternative preventive option when first-line treatments fail 2

Other Treatment Options

1. Non-invasive Vagus Nerve Stimulation

   • Recommended for episodic cluster headache 1, 2
   • Not effective for chronic cluster headache 2

2. Alternative Preventives

   • Lithium and topiramate may be considered when first-line treatments fail 2, 8
   • Melatonin has some evidence of efficacy 8

Treatment Algorithm

1. For Acute Attacks:

   • Start with high-flow oxygen if available (12-15 L/min)
   • If inadequate response or unavailable, use subcutaneous sumatriptan 6 mg
   • If sumatriptan is contraindicated, use intranasal zolmitriptan 10 mg

2. For Prevention:

   • Episodic cluster headache: Start with galcanezumab
   • Chronic cluster headache: Start with verapamil (with appropriate cardiac monitoring)
   • Consider bridge therapy with corticosteroids while waiting for preventives to take effect

Important Clinical Considerations

• Begin treatment immediately at the onset of an attack for maximum effectiveness 2
• Counsel patients to avoid known triggers, particularly alcohol 2
• Opioids should be avoided due to risk of dependency and rebound headaches 2
• Regular evaluation of treatment efficacy is necessary to adjust therapy 2
• Non-oral routes of administration provide better and more rapid responses for acute treatment 4
• Patients should be educated about having rescue medication readily available during cluster periods 2