What are the treatment options for cluster headaches?

Cluster Headache Treatment

High-flow oxygen therapy (12-15 L/min via non-rebreather mask for 15 minutes) and subcutaneous sumatriptan (6 mg) are the first-line abortive treatments for cluster headache attacks. 1

Abortive (Acute) Treatments

First-Line Options:

• High-flow oxygen therapy

  • 12-15 L/min via non-rebreather mask for 15 minutes
  • Effective in 78% of patients within 15 minutes 2
  • No significant adverse events reported
  • Should be arranged with provision for urgent 4-hour installation when a cluster period begins

• Subcutaneous sumatriptan (6 mg)

  • Provides relief within 10-15 minutes in 49-74% of patients 1
  • FDA-approved specifically for cluster headache 3
  • Clinical trials showed 49% effectiveness at 10 minutes and 74% at 15 minutes 3
  • Contraindicated in patients with cardiovascular disease

Second-Line Options:

• Intranasal zolmitriptan (10 mg) 1
  • Consider when sumatriptan is contraindicated
  • 62% effectiveness at 30 minutes 4

Preventive Treatments

First-Line Options:

• Verapamil (for both episodic and chronic cluster headache)

  • Minimum effective dose: 240 mg daily 1, 5
  • Requires cardiac monitoring with ECG before initiation and with dose increases
  • Maximum dose depends on efficacy and tolerability

• Galcanezumab (for episodic cluster headache only)

  • Not effective for chronic cluster headache 1, 6

Bridge Therapy:

• Corticosteroids (short-term use until preventive medications take effect)
  • Prednisone 100 mg orally or up to 500 mg IV daily for 5 days 1, 5
  • Greater occipital nerve blocks 1, 5

Alternative Preventive Options:

• Non-invasive vagus nerve stimulation (for episodic cluster headache) 1, 6
• Lithium (particularly effective for chronic cluster headache) 5, 7
• Topiramate 1, 5
• Melatonin 7

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 sumatriptan is contraindicated, use intranasal zolmitriptan 10 mg

2. For prevention:

   • Episodic cluster headache: Start with galcanezumab or verapamil (≥240 mg daily)
   • Chronic cluster headache: Start with verapamil (≥240 mg daily)
   • Consider bridge therapy with corticosteroids while waiting for preventive medications to take effect

Important Considerations and Pitfalls

• Timing is critical: Patients should begin treatment immediately at the onset of an attack for maximum effectiveness 1
• Avoid alcohol: Patients should be counseled to avoid known triggers, particularly alcohol 1
• Avoid opioids: These should not be used for cluster headache due to risk of dependency and rebound headaches 1
• Botulinum toxin (Botox) is not recommended for cluster headache due to insufficient evidence 1
• Cardiac monitoring: ECG monitoring is essential for patients on verapamil, before initiation and with dose increases 1
• Oxygen delivery: Oxygen concentrators can be an effective alternative to oxygen tanks with similar efficacy 1
• Medication availability: Patients should be educated about the importance of having rescue medication readily available during cluster periods 1

Non-oral routes of administration (subcutaneous, intranasal, inhaled) provide better and more rapid responses compared to oral medications due to the rapid onset and relatively short duration of cluster headache attacks 4.