What is the recommended treatment for cluster headaches?

Treatment of Cluster Headache

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

Acute Treatment Options

First-line Treatments

• High-flow oxygen therapy

  • Administer 100% oxygen at 12-15 L/min via non-rebreather mask for 15 minutes
  • Provides relief in 78% of attacks within 15 minutes 2
  • No contraindications, can be used multiple times daily
  • Arrange for home oxygen with provision for urgent 4-hour installation when a cluster period begins 1

• Subcutaneous sumatriptan (6 mg)

  • Provides relief within 10-15 minutes in 49-74% of patients 1
  • FDA-approved for cluster headache with 74% efficacy at 15 minutes post-injection 3
  • Contraindicated in patients with cardiovascular disease
  • Can be self-administered using an autoinjector 3

Second-line Treatment

• Intranasal zolmitriptan (10 mg) when sumatriptan is contraindicated 1

Preventive Treatment Options

First-line Preventive Treatments

• For episodic cluster headache:

  • Galcanezumab (monoclonal antibody to CGRP) 1, 4

• For chronic cluster headache:

  • Verapamil (at least 240 mg daily) 1, 4
    • Requires ECG monitoring before initiation and with dose increases
    • Maximum dose depends on efficacy and tolerability 4

Bridging Therapy

• Corticosteroids (short-term)
  • At least 100 mg prednisone orally or up to 500 mg IV daily for 5 days 1, 4
  • Used until preventive medications take effect

Alternative Preventive Options

• Non-invasive vagus nerve stimulation for episodic cluster headache (not effective for chronic) 1, 4
• Greater occipital nerve blocks 1, 4
• Lithium 1, 4
• Topiramate 1, 4

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:

   • For episodic cluster headache: Start galcanezumab
   • For chronic cluster headache: Start verapamil (at least 240 mg daily)
   • Consider bridge therapy with corticosteroids until preventive medications take effect

Important Considerations and Pitfalls

• Begin treatment immediately at the onset of an attack for maximum effectiveness 1
• Avoid opioids for cluster headache treatment due to risk of dependency and rebound headaches 1
• Monitor for medication overuse headache, defined as headache occurring on 15+ days per month for at least 3 months due to overuse of acute medication 5
• Counsel patients to avoid triggers, particularly alcohol 1
• For patients on verapamil, cardiac monitoring is necessary with ECG before initiation and with dose increases 1
• Oxygen concentrators can be an effective alternative to oxygen tanks with similar efficacy 1
• Ensure patients have rescue medication readily available during cluster periods 1

The European Academy of Neurology guidelines strongly support these recommendations, particularly emphasizing the efficacy of oxygen and subcutaneous sumatriptan for acute treatment, and verapamil, corticosteroids, and galcanezumab (for episodic cluster headache only) for prevention 4.