What is the recommended management for cluster headaches?

Management 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), while verapamil (at least 240 mg daily) and galcanezumab are the preferred preventive treatments for chronic and episodic cluster headache, respectively. 1

Acute Treatment Options

First-Line Treatments

• High-flow oxygen therapy (12-15 L/min):

  • Provides relief in 78% of patients within 15 minutes 2
  • Should be administered via non-rebreather mask for 15 minutes
  • No significant adverse effects, making it suitable for patients with cardiovascular contraindications 1, 3
  • Patients should begin treatment immediately at attack onset for maximum effectiveness

• Subcutaneous sumatriptan (6 mg):

  • Provides relief within 10-15 minutes in 49-74% of patients
  • Contraindicated in patients with cardiovascular disease 1

Second-Line Treatments

• Intranasal zolmitriptan (10 mg): Alternative when sumatriptan is contraindicated 1, 4
• Dihydroergotamine: May be effective for some patients 5, 6

Preventive Treatment Strategy

For Episodic Cluster Headache

1. Galcanezumab: First-line for episodic cluster headache prevention (monoclonal antibody to CGRP) 1
2. Non-invasive vagus nerve stimulation: Recommended with moderate supporting evidence 1

For Chronic Cluster Headache

1. Verapamil (at least 240 mg daily):

   • First-line preventive treatment
   • Requires ECG monitoring before initiation and with dose increases
   • Monitor for cardiac conduction abnormalities 1, 4

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

   • Lithium
   • Topiramate
   • Greater occipital nerve blocks
   • Gabapentin
   • Divalproex sodium
   • Melatonin 1, 4

Bridging Therapy

• Corticosteroids: Short-term use until preventive medications take effect
  • Typically at least 100 mg prednisone orally or up to 500 mg IV daily for 5 days 1
  • Alternatively, occipital nerve blocks can be used 1, 4

Important Clinical Considerations

Treatment Pitfalls to Avoid

• Avoid opioids: 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 1
• Do not use galcanezumab for chronic cluster headache: Evidence shows it's ineffective in this subtype 1

Practical Implementation Tips

• Ensure patients have rescue medication readily available during cluster periods 1
• Arrange for home oxygen with provision for urgent 4-hour installation when a cluster period begins 1
• Counsel patients to avoid triggers, particularly alcohol 1
• Educate patients to begin treatment immediately at attack onset 1, 3
• Consider oxygen concentrators as an effective alternative to oxygen tanks 1

Monitoring Requirements

• Regular evaluation of treatment efficacy to adjust therapy
• ECG monitoring before initiation of verapamil and with dose increases 1, 6
• Patients with cardiac conditions, hypertension, or hypotension should be carefully evaluated before starting vagus nerve stimulation 1

Diagnostic Considerations

• Brain MRI is warranted in the initial workup to exclude structural mimics 5
• Recognize the distinctive circadian and circannual periodicity in episodic forms 5, 6