What are the treatment options for cluster headaches?

Treatment Options for Cluster Headache

For cluster headache treatment, subcutaneous sumatriptan (6 mg), intranasal zolmitriptan (10 mg), and normobaric oxygen therapy are the most effective abortive treatments, while galcanezumab is recommended for prevention of episodic (but not chronic) cluster headache. 1

Abortive Treatment Options

First-Line Abortive Treatments

1. Subcutaneous Sumatriptan (6 mg)

   • Provides rapid relief within 15 minutes in 75% of patients (compared to 32% with placebo) 2, 3
   • FDA-approved specifically for cluster headache 2
   • Highly effective with an NNT of 2.4 for 15-minute pain relief 3
   • Particularly useful for severe attacks or those with significant nausea/vomiting 1

2. Intranasal Zolmitriptan (10 mg)

   • Provides 30-minute pain relief with an NNT of 2.8 3
   • 62% of patients achieve relief at 30 minutes (vs 26% with placebo) 3

3. Normobaric Oxygen Therapy

   • Recommended at flow rates of at least 12 L/min for 15 minutes 4
   • Non-pharmacological option with minimal side effects 1
   • Particularly useful for patients with cardiovascular contraindications to triptans

Route of Administration Considerations

• Non-oral routes are preferred due to:
  • Rapid onset of action needed for the severe, but brief cluster attacks 3
  • Better absorption and bioavailability 3
  • Potential for nausea during attacks 5

Preventive Treatment Options

First-Line Preventive Treatment

• Galcanezumab
  • Recommended for prevention of episodic cluster headache 1
  • Not recommended for chronic cluster headache 1

Other Preventive Options

• Verapamil

  • Insufficient evidence to make a firm recommendation for either episodic or chronic cluster headache 1
  • However, considered a standard preventive treatment in clinical practice 4, 6
  • Typically requires doses of at least 240 mg daily 4
  • ECG monitoring recommended due to potential cardiac effects 6

• Corticosteroids

  • Often used as "bridge therapy" until other preventives take effect 6, 7
  • Typically administered as oral prednisone (at least 100 mg) or equivalent 4
  • Short-term use only due to side effect profile with prolonged use

Neuromodulation Options

• Non-invasive vagus nerve stimulation

  • Recommended for episodic cluster headache 1, 4
  • Not effective for chronic cluster headache 4

• Against implantable sphenopalatine ganglion stimulator 1

Treatment Algorithm

For Acute Attacks:

1. First-line: Try oxygen therapy (12+ L/min for 15 minutes) if available
2. Alternative first-line: Subcutaneous sumatriptan 6 mg if no cardiovascular contraindications
3. Second-line: Intranasal zolmitriptan 10 mg if subcutaneous injection not feasible

For Prevention:

1. For episodic cluster headache: Galcanezumab
2. Bridge therapy: Short course of corticosteroids while waiting for preventive medication to take effect
3. Alternative options: Consider verapamil (with appropriate cardiac monitoring) or non-invasive vagus nerve stimulation for episodic cluster headache

Common Pitfalls and Caveats

• Medication overuse: Limit acute medications to prevent medication overuse headache 1
• Cardiovascular risk: Screen for cardiovascular contraindications before prescribing triptans 2
• Oxygen administration: Ensure proper flow rate (minimum 12 L/min) and duration (15 minutes) for effectiveness 4
• Chronic vs. episodic: Treatment approaches differ - galcanezumab is not recommended for chronic cluster headache 1
• ECG monitoring: Required when initiating verapamil due to potential cardiac conduction abnormalities 6