What is the treatment plan for an adult patient with cluster headaches?

Treatment Prescription for Adult Cluster Headache

High-flow oxygen therapy at 12-15 L/min via non-rebreather mask for 15 minutes is the first-line treatment for acute cluster headache attacks. 1

Acute Treatment Options

First-Line Treatments

1. High-Flow Oxygen Therapy

   • Dosage: 12-15 L/min via non-rebreather mask
   • Duration: 15 minutes per attack
   • Efficacy: Provides relief in 78% of attacks (vs. 20% for placebo) 2
   • Arrange for home oxygen with provision for urgent 4-hour installation when a cluster period begins

2. Subcutaneous Sumatriptan

   • Dosage: 6 mg subcutaneously
   • Onset: Relief within 10-15 minutes in 49-74% of patients
   • Contraindication: Cardiovascular disease 1
   • Maximum: 2 injections per 24 hours, separated by at least 1 hour

Alternative Acute Treatments

• Intranasal Zolmitriptan
  • Dosage: 10 mg intranasally
  • Use when sumatriptan is contraindicated 1

Preventive Treatment

For Episodic Cluster Headache

1. Galcanezumab

   • Dosage: 300 mg (three consecutive 100 mg subcutaneous injections)
   • Frequency: At onset of cluster period, then monthly until end of cluster period 3
   • Note: Specifically indicated for episodic cluster headache

2. Verapamil

   • Starting dose: 240 mg daily (divided doses)
   • Titration: Increase by 80 mg every 2 weeks as needed
   • Monitoring: ECG before initiation and with each dose increase 1

Bridging Therapy (Short-term)

• Corticosteroids
  • Dosage: Prednisone 100 mg orally daily for 5 days, then taper
  • Purpose: Used until preventive medications take effect 1

Additional Preventive Options

• Non-invasive vagus nerve stimulation for episodic cluster headache
• Greater occipital nerve blocks as alternative when first-line treatments fail

Important Clinical Considerations

1. Medication Overuse Risk

   • Limit acute therapy to prevent medication-overuse headache
   • Monitor for headaches occurring on 15+ days per month for at least 3 months 1

2. Avoid Opioids

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

3. Trigger Avoidance

   • Counsel patient to avoid triggers, particularly alcohol 1

4. Treatment Timing

   • Begin treatment immediately at onset of attack for maximum effectiveness
   • Ensure rescue medication is readily available during cluster periods 1

5. Treatment Monitoring

   • Regular evaluation of treatment efficacy to adjust therapy
   • Cardiac monitoring for patients on verapamil 1

Prescription Example

Rx: Oxygen Therapy
Dosage: 100% oxygen at 12-15 L/min via non-rebreather mask
Duration: 15 minutes per attack
Dispense: Home oxygen setup with non-rebreather masks
Refills: As needed during cluster periods

Rx: Sumatriptan Injection
Dosage: 6 mg subcutaneous injection at onset of attack
Maximum: 2 injections per 24 hours, separated by at least 1 hour
Dispense: 6 prefilled syringes
Refills: 2

Rx: Verapamil
Dosage: 80 mg tablets
Sig: Take 1 tablet three times daily (240 mg/day)
Dispense: 90 tablets
Refills: 2
Note: ECG required before initiation and with dose increases

Rx: Prednisone (for bridging)
Dosage: 20 mg tablets
Sig: Take 5 tablets (100 mg) daily for 5 days, then 4 tablets daily for 2 days, 3 tablets daily for 2 days, 2 tablets daily for 2 days, 1 tablet daily for 2 days, then discontinue
Dispense: 30 tablets
Refills: 0

This treatment plan prioritizes the most effective interventions for reducing morbidity and improving quality of life in cluster headache patients, with high-flow oxygen as the cornerstone of acute treatment due to its superior efficacy and safety profile.