What are the treatment options for cluster headaches?

Treatment Options for Cluster Headaches

High-flow oxygen therapy (12-15 L/min via non-rebreather mask for 15 minutes) is the first-line treatment for acute cluster headache attacks, providing relief in a significant proportion of patients with minimal adverse effects. 1

Acute Treatment Options

First-Line Treatments

1. High-flow oxygen therapy

   • Flow rate: 12-15 L/min via non-rebreather mask
   • Duration: At least 15 minutes
   • Administration: Begin immediately at attack onset
   • Efficacy: 78% of patients achieve pain freedom at 15 minutes 2
   • Safety: Remarkably safe with minimal adverse effects 1
   • Practical considerations:
     • Arrange for urgent 4-hour installation of home oxygen when a cluster period begins
     • Oxygen concentrators can be an effective alternative to oxygen tanks 3

2. Subcutaneous sumatriptan (6 mg)

   • Efficacy: 49% of patients achieve pain relief at 10 minutes, 74-75% at 15 minutes 4
   • Contraindications: Cardiovascular disease 1
   • Administration: Self-administration using autoinjector

Alternative Acute Treatments

• Intranasal zolmitriptan (10 mg) - When sumatriptan is contraindicated 1
• Intranasal sumatriptan - Alternative when other options unavailable 1

Preventive Treatment Options

First-Line Preventive Treatments

1. For episodic cluster headache:

   • Galcanezumab (monoclonal antibody to CGRP) - High level of evidence for efficacy
   • Non-invasive vagus nerve stimulation - Moderate evidence for efficacy
   • Verapamil (at least 240 mg daily) - Requires ECG monitoring before initiation and with dose increases

2. For chronic cluster headache:

   • Verapamil (at least 240 mg daily) - Moderate evidence for efficacy
   • Lithium - Alternative option when first-line treatments fail

Bridging Therapy

• Corticosteroids (short-term)

  • Dosage: At least 100 mg prednisone orally or up to 500 mg IV daily for 5 days
  • Purpose: Used until preventive medications take effect 1, 5

• Greater occipital nerve blocks - Alternative bridging option 1, 5

Alternative Preventive Options

• Topiramate
• Melatonin
• Gabapentin
• Divalproex sodium 6

Treatment Algorithm

1. For acute attacks:

   • Start with high-flow oxygen (12-15 L/min via non-rebreather mask)
   • If oxygen unavailable or insufficient, use subcutaneous sumatriptan 6 mg
   • If sumatriptan contraindicated, use intranasal zolmitriptan 10 mg

2. For prevention:

   • Episodic cluster headache: Start with galcanezumab or verapamil (with ECG monitoring)
   • Chronic cluster headache: Start with verapamil (with ECG monitoring)
   • Use corticosteroids as bridging therapy until preventive medications take effect
   • If first-line treatments fail, consider lithium, topiramate, or greater occipital nerve blocks

Important Clinical Considerations

• Timing is critical: Begin treatment immediately at attack onset for maximum effectiveness 1
• 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
• Patient education: Counsel patients to avoid triggers, particularly alcohol 1
• ECG monitoring: Required for patients on verapamil, before initiation and with dose increases 1
• Home oxygen considerations: Recent research shows that home oxygen concentrators can effectively supply oxygen similar to tanks 3, 7

Treatment Efficacy Comparison

• High-flow oxygen: 78% pain-free at 15 minutes vs. 20% with placebo 2
• Subcutaneous sumatriptan: 74-75% pain relief at 15 minutes vs. 26-35% with placebo 4
• Oxygen from concentrators: 31.7% substantial pain reduction at 15 minutes vs. 12.9% with oral zolmitriptan 3

The evidence strongly supports high-flow oxygen as first-line therapy due to its excellent efficacy and safety profile, with subcutaneous sumatriptan as an effective alternative when oxygen is unavailable or insufficient.